Heat stress, dehydration and kidney dysfunction were most common among sugarcane cutters. Kidney dysfunction also occurred to a lesser extent among construction workers, but hardly at all among small-scale farmers. High serum uric acid was associated with reduced kidney function.

The aim of this study was to develop a critical appraisal (CA) tool that addressed study design and reporting quality as well as the risk of bias in cross-sectional studies (CSSs). In addition, the aim was to produce a help document to guide the non-expert user through the tool.

Design

An initial scoping review of the published literature and key epidemiological texts was undertaken prior to the formation of a Delphi panel to establish key components for a CA tool for CSSs. A consensus of 80% was required from the Delphi panel for any component to be included in the final tool.

Results

An initial list of 39 components was identified through examination of existing resources. An international Delphi panel of 18 medical and veterinary experts was established. After 3 rounds of the Delphi process, the Appraisal tool for Cross-Sectional Studies (AXIS tool) was developed by consensus and consisted of 20 components. A detailed explanatory document was also developed with the tool, giving expanded explanation of each question and providing simple interpretations and examples of the epidemiological concepts being examined in each question to aid non-expert users.

Conclusions

CA of the literature is a vital step in evidence synthesis and therefore evidence-based decision-making in a number of different disciplines. The AXIS tool is therefore unique and was developed in a way that it can be used across disciplines to aid the inclusion of CSSs in systematic reviews, guidelines and clinical decision-making.

Analysis shows that these patients have difficulties accepting their life situation and feel at the mercy of the disease, which could be identified as a core-experienced phenomenon. Over a long period of time, patients have only a vague feeling of being ill, caused by uncertain knowledge, slow progress and doubtful attribution of clinical symptoms of the disease (causal conditions). As an action strategy, patients try to maintain daily routines for as long as possible after diagnosis. Both effective standard and rescue medication, which helps to reduce breathlessness and other symptoms, and the feeling of being faced with one's own responsibility (intervening conditions) support this strategy, whereby patients' own responsibility is too painful to acknowledge. As a consequence, patients try to deny the threat to life for a long period of time. Frequently, they need to experience facing their own limits, often in the form of an acute crisis, to realise their health situation. The experience of the illness is contextualised by a continuous increase in limited mobility and social isolation.

Conclusion

In order to help patients to improve disease awareness, to accept their life situation and to improve their reduced quality of life, patients may benefit from the early integration of palliative care (PC), considering its multiprofessional patient-centred and team-centred approach. Psychological support and volunteer work, which are relevant aspects of PC, should be appropriate to address psychosocial needs. More research is needed to evaluate how patients could benefit from early PC.

The number of patients using second-line antiretroviral therapy (ART) has increased over time. In Ethiopia, 1.5% of HIV infected patients on ART are using a second-line regimen and little is known about its effect in this setting.

Objective

To estimate the rate and predictors of treatment failure on second-line ART among adults living with HIV in northwest Ethiopia.

Setting

An institution-based retrospective follow-up study was conducted at three tertiary hospitals in northwest Ethiopia from March to May 2015.

Participants

356 adult patients participated and 198 (55.6%) were males. Individuals who were on second-line ART for at least 6 months of treatment were included and the data were collected by reviewing their records.

Primary outcome measure

The primary outcome was treatment failure defined as immunological failure, clinical failure, death, or lost to follow-up. To assess our outcome, we used the definitions of the WHO 2010 guideline.

Result

The mean±SD age of participants at switch was 36±8.9 years. The incidence rate of failure was 61.7/1000 person years. The probability of failure at the end of 12 and 24 months were 5.6% and 13.6%, respectively. Out of 67 total failures, 42 (62.7%) occurred in the first 2 years. The significant predictors of failure were found to be: WHO clinical stage IV at switch (adjusted HR (AHR) 2.1, 95% CI 1.1 to 4.1); CD4 count <100 cells/mm3 at switch (AHR 2.0, 95% CI 1.2 to 3.5); and weight change (AHR 0.92, 95% CI 0.88 to 0.95).

Conclusions

The rate of treatment failure was highest during the first 2 years of treatment. WHO clinical stage, CD4 count at switch, and change in weight were found to be predictors of treatment failure.

To explore patterns of non-communicable diseases (NCDs) in the Australian Capital Territory (ACT).To ascertain the effect of the neighbourhood built environmental features and especially walkability on health outcomes, specifically for hospital admissions from NCDs.

Design

A cross-sectional analysis of public hospital episode data (2007–2013).

Setting

Hospitalisations from the ACT, Australia at very small geographic areas.

Participants

Secondary data on 75 290 unique hospital episodes representing 39 851 patients who were admitted to ACT hospitals from 2007 to 2013. No restrictions on age, sex or ethnicity.

Geographic clusters with significant high and low risks of NCDs were found that displayed an overall geographic pattern of high risk in the outlying suburbs of the territory. Significant relationships between neighbourhood walkability as measured by Walk Score and the likelihood of hospitalisation with a primary diagnosis of myocardial infarction (heart attack) were found. A possible relationship was also found with the likelihood of being hospitalised with 4 major lifestyle-related cancers.

Conclusions

Our research augments the growing literature underscoring the relationships between the built environment and health outcomes. In addition, it supports the importance of walkable neighbourhoods, as measured by Walk Score, for improved health.

WHO advocates 2-hour oral glucose tolerance test (OGTT) for detecting diabetes mellitus (DM). OGTT is the most sensitive method to detect DM in patients with coronary artery disease (CAD). Considered time consuming, the use of OGTT is unsatisfactory. A 1-hour plasma glucose (1hPG) test has not been evaluated as an alternative in patients with CAD.

Objectives

To create an algorithm based on glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and 1hPG limiting the need of a 2-hour plasma glucose (2hPG) in patients with CAD.

Methods

951 patients with CAD without DM underwent OGTT. A 2hPG≥11.1 mmol/L was the reference for undiagnosed DM. The yield of HbA1c, FPG and 1hPG was compared with that of 2hPG.

Results

Mean FPG was 6.2±0.9 mmol/L, and mean HbA1c 5.8±0.4%. Based on 2hPG≥11.1 mmol/L 122 patients (13%) had DM. There was no value for the combination of HbA1c and FPG to rule out or in DM (HbA1c≥6.5%; FPG≥7.0 mmol/L). In receiver operating characteristic analysis a 1hPG≥12 mmol/L balanced sensitivity and specificity for detecting DM (both=82%; positive and negative predictive values 40% and 97%). A combination of FPG<6.5 mmol/L and 1hPG<11 mmol/L excluded 99% of DM. A combination of FPG>8.0 mmol/L and 1hPG>15 mmol/L identified 100% of patients with DM.

Conclusions

Based on its satisfactory accuracy to detect DM an algorithm is proposed for screening for DM in patients with CAD decreasing the need for a 2-hour OGTT by 71%.

To (1) assess the hydration knowledge, attitudes and practices (KAP) of doctors; (2) develop an evidence-based training package; and (3) evaluate the impact of the training package.

Design

Educational intervention with impact evaluation.

Setting

Cambridgeshire, UK.

Participants

General practitioners (GPs (primary care physicians)).

Interventions

Hydration and healthcare training.

Main outcome measures

Hydration KAP score before and immediately after the training session.

Results

Knowledge gaps of doctors identified before the teaching were the definition of dehydration, European Food Safety Authority water intake recommendations, water content of the human body and proportion of water from food and drink. A face-to-face teaching package was developed on findings from the KAP survey and literature search. 54 questionnaires were completed before and immediately after two training sessions with GPs. Following the training, total hydration KAP scores increased significantly (p<0.001; median (25th, 75th centiles); 32 (29, 34)). Attendees rated the session as excellent or good (90%) and reported the training was likely to influence their professional practice (100%).

Conclusions

The training package will continue to be developed and adapted, with increased focus on follow-up strategies as well as integration into medical curricula and standards of practice. However, further research is required in the area of hydration care to allow policymakers to incorporate hydration awareness and care with greater precision in local and national policies.

Efforts to improve healthcare and population health depend partly on the ability of health organisations to use research knowledge and participate in its production. We report the findings of a survey conducted to prioritise training needs among healthcare and public health staff, in relation to the production and implementation of research, across an applied health research collaboration.

Design

A questionnaire survey using a validated tool, the Hennessy-Hicks Training Needs Assessment Questionnaire. Participants rated 25 tasks on a five-point scale with regard to both their confidence in performing the task, and its importance to their role.

Setting

A questionnaire weblink was distributed to a convenience sample of 35 healthcare and public health organisations in London and South East England, with a request that they cascade the information to relevant staff.

Participants

203 individuals responded, from 20 healthcare and public health organisations.

Interventions

None.

Outcome measures

Training needs were identified by comparing median importance and performance scores for each task. Individuals were also invited to describe up to three priority areas in which they require training.

Results

Across the study sample, evaluation; teaching; making do with limited resources; coping with change and managing competing demands were identified as key tasks. Assessing the relevance of research and learning about new developments were the most relevant research-related tasks. Participants’ training priorities included evaluation; finding, appraising and applying research evidence; and data analysis. Key barriers to involvement included time and resources, as well as a lack of institutional support for undertaking research.

Conclusions

We identify areas in which healthcare and public health professionals may benefit from support to facilitate their involvement in and use of applied health research. We also describe barriers to participation and differing perceptions of research between professional groups.

Approaches to measuring intimate partner violence (IPV) in populations often privilege physical violence, with poor assessment of other experiences. This has led to underestimating the scope and impact of IPV. The aim of this study was to develop a brief, reliable and valid self-report measure of IPV that adequately captures its complexity.

Design

Mixed-methods instrument development and psychometric testing to evolve a brief version of the Composite Abuse Scale (CAS) using secondary data analysis and expert feedback.

Setting

Data from 5 Canadian IPV studies; feedback from international IPV experts.

Participants

31 international IPV experts including academic researchers, service providers and policy actors rated CAS items via an online survey. Pooled data from 6278 adult Canadian women were used for scale development.

A 15-item version of the CAS has been developed (Composite Abuse Scale (Revised)—Short Form, CASR-SF), including 12 items developed from the original CAS and 3 items suggested through expert consultation and the evolving literature. Items cover 3 abuse domains: physical, sexual and psychological, with questions asked to assess lifetime, recent and current exposure, and abuse frequency. Factor loadings for the final 3-factor solution ranged from 0.81 to 0.91 for the 6 psychological abuse items, 0.63 to 0.92 for the 4 physical abuse items, and 0.85 and 0.93 for the 2 sexual abuse items. Moderate correlations were observed between the CASR-SF and measures of depression, post-traumatic stress disorder and coercive control. Internal consistency of the CASR-SF was 0.942. These reliability and validity estimates were comparable to those obtained for the original 30-item CAS.

Conclusions

The CASR-SF is brief self-report measure of IPV experiences among women that has demonstrated initial reliability and validity and is suitable for use in population studies or other studies. Additional validation of the 15-item scale with diverse samples is required.

Groups P1 and P2 had the highest proportion of women. P2 and P4 had higher mean ages and comorbidity counts. P3 and P4 had higher proportions of overweight/obese individuals and lower general health scores. Adjusted models: being male and overweight/obese was associated with increased odds of being in P3 (OR 1.64 (95% CI 1.10 to 2.46), and OR 1.74 (1.13 to 2.68), respectively) and P4 (OR 1.87 (1.11 to 3.15) and OR 1.91 (1.06 to 3.42), respectively), and increasing age with increased odds of being in P2 (OR 1.02 (1.01 to 1.03)) and P4 (OR 1.06 (1.04 to 1.08)). Increasing comorbidity count was associated with increased odds of being in P2 (OR 1.14 (1.0 to 1.3)), and better general health scores with decreased odds of being in P3 (OR 0.40 (0.18 to 0.93)).

Conclusions

This is the first study to examine the ‘Hall system’ in a non-rehab primary care population. Subgroups classified according to this system appear to have distinct profiles. Further research is needed to better characterise and determine the prognostic implication of these clinically derived subgroups.

To develop an inclusive model of culturally sensitive support, using a specialist dementia nurse (SDN), to assist people with dementia from culturally and linguistically diverse (CALD) communities and their carers to overcome barriers to accessing health and social care services.

Design

Co-creation and participatory action research, based on reflection, data collection, interaction and feedback from participants and stakeholders.

Setting

An SDN support model embedded within a home nursing service in Melbourne, Australia was implemented between October 2013 and October 2015.

Participants

People experiencing memory loss or with a diagnosis of dementia from CALD backgrounds and their carers and family living in the community setting and expert stakeholders.

Data collection and analysis

Reflections from the SDN on interactions with participants and expert stakeholder opinion informed the CALD dementia support model and pathway.

Results

Interaction with 62 people living with memory loss or dementia from CALD backgrounds, carers or family members receiving support from the SDN and feedback from 13 expert stakeholders from community aged-care services, consumer advocacy organisations and ethnic community group representatives informed the development and refinement of the CALD dementia model of care and pathway. We delineate the three components of the ‘SDN’ model: the organisational support; a description of the role; and the competencies needed. Additionally, we provide an accompanying pathway for use by health professionals delivering care to consumers with dementia from CALD backgrounds.

Conclusions

Our culturally sensitive model of dementia care and accompanying pathway allows for the tailoring of health and social support to assist people from CALD backgrounds, their carers and families to adjust to living with memory loss and remain living in the community as long as possible. The model and accompanying pathway also have the potential to be rolled out nationally for use by health professionals across a variety of health services.

The metabolic syndrome (MetS) indicates increased risk for cardiovascular disease and type 2 diabetes. We estimated the overall and ethnic-specific prevalence of MetS and explored the associations of risk factors with MetS among Amerindian, Creole, Hindustani, Javanese, Maroon and Mixed ethnic groups.

Method

We used the 2009 Joint Interim Statement (JIS) to define MetS in a subgroup of 2946 participants of the Suriname Health Study, a national survey designed according to the WHO Steps guidelines. The prevalences of MetS and its components were determined for all ethnicities. Hierarchical logistic regressions were used to determine the associations of ethnicity, sex, age, marital status, educational level, income status, employment, smoking status, residence, physical activity, fruit and vegetable intake with MetS.

Results

The overall estimated prevalence of MetS was 39.2%. From MetS components, central obesity and low high-density lipoprotein cholesterol (HDL-C) had the highest prevalences. The prevalence of MetS was highest for the Hindustanis (52.7%) and lowest for Maroons (24.2%). The analyses showed that in the overall population sex (women: OR 1.4; 95% CI 1.2 to 1.6), age (OR 5.5 CI 4.3 to 7.2), education (OR 0.7 CI 0.6 to 0.9), living area (OR 0.6 CI 0.5 to 0.8), income (OR 0.7 CI 0.5 to 0.9) and marital status (OR 1.3 CI 1.1 to 1.6) were associated with MetS. Variations observed in the associations of the risk factors with MetS in the ethnic groups did not materially influence the associations of ethnicities with MetS.

Conclusions

The prevalence of MetS was high and varied widely among ethnicities. Overall, central obesity and low HDL-C contributed most to MetS. Further studies are needed to assess the prospective associations of risk factors with MetS in different ethnic groups.

To quantify the 12-month hospitalised morbidity and mortality attributable to traumatic injury using a population-based matched cohort in Australia.

Setting

New South Wales, Queensland and South Australia, Australia.

Participants

Individuals ≥18 years who had an injury-related hospital admission in 2009 formed the injured cohort. The non-injured comparison cohort was randomly selected from the electoral roll and was matched 1:1 on age, gender and postcode of residence at the date of the index injury admission of their matched counterpart.

Primary outcome measures

Using linked emergency department presentation, hospital admission and mortality records from 1 January 2008 to 31 December 2010 for both the injured and non-injured cohorts, 12-month mortality and pre-index and post-index injury hospital service use was examined. Adjusted rate ratios and attributable risk were calculated.

Results

There were 167 600 individuals injured in 2009 and admitted to hospital in New South Wales, South Australia or Queensland with a matched comparison. The injured cohort had 3 times higher proportion of having ≥1 comorbidity preinjury, higher preinjury hospital service use, and a higher 12-month mortality compared with a non-injured comparison group. The injured cohort had 2.20 (95% CI 2.12 to 2.28) times higher rate of hospital admissions in the 12 months post the index injury admission compared with the non-injured comparison cohort. Injury was a likely contributory factor in at least 55% of hospitalisations within 12 months of the index injury hospitalisation.

Conclusions

Individuals who had an injury-related hospitalisation had higher mortality and are hospitalised at increased rates for many months postinjury. While comorbid conditions are significant, they do not account for the differences in outcomes. This study contributes to informing research efforts on better quantifying the attributable burden of hospitalised injury-related disability and mortality in Australia.

Response rate in public health programmes may be a limiting factor. It is important to first consider their delivery and acceptability for the target. This study aimed at determining individual and unit-related factors associated with increased odds of non-response based on hepatitis C virus screening in primary healthcare.

Design

Primary healthcare units (PHCUs) were extracted from the Register of Health Care Centres. Each of the PHCUs was to enrol adult patients selected on a random basis. Data on the recruitment of PHCUs and patients were analysed. Multilevel modelling was applied to investigate individual and unit-related factors associated with non-response. Multilevel logistic model was developed with fixed effects and only a random intercept for the unit. Preliminary analysis included a random effect for unit and each of the individual or PHCU covariates separately. For each of the PHCU covariates, we applied a two-level model with individual covariates, unit random effect and a single fixed effect of this unit covariate.

Setting

This study was conducted in primary care units in selected provinces in Poland.

Participants

A total of 242 PHCUs and 24 480 adults were invited. Of them, 44 PHCUs and 20 939 patients agreed to participate. Both PHCUs and patients were randomly selected.

Results

Data on 44 PHCUs and 24 480 patients were analysed. PHCU-level factors and recruitment strategies were important predictors of non-response. Unit random effect was significant in all models. Larger and private units reported higher non-response rates, while for those with a history of running public health programmes the odds of non-response was lower. Proactive recruitment, more working hours devoted to the project and patient resulted in higher acceptance of the project. Higher number of personnel had no such effect.

Conclusions

Prior to the implementation of public health programme, several factors that could hinder its execution should be addressed.

183 903 non-obese individuals were enrolled from a cross-sectional population, and a total of 16 173 initially NAFLD-free non-obese individuals were included who completed a 5-year follow-up examination in the longitudinal population.

Results

In our study, NAFLD was defined by ultrasonographic detection of steatosis in the absence of other liver disease. The cross-sectional study showed that at baseline, the prevalence of NAFLD was 13.9% in non-obese individuals with normal LDL-c levels. The prospective study demonstrated that NAFLD-free participants developed NAFLD during the 5-year follow-up period, with a cumulative incidence of 14.4%. In addition, the ORs for NAFLD in the cross-sectional population were 1.11 (95% CI 1.04 to 1.18), 1.37 (95% CI 1.27 to 1.47) and 1.56 (95% CI 1.43 to 1.69), respectively, after adjusting for known confounding variables. The HRs for NAFLD in the longitudinal population were 1.15 (95% CI 0.98 to 1.36), 1.32 (95% CI 1.10 to 1.58) and 1.82 (95% CI 1.47 to 2.52), compared with Q1. Individuals with higher LDL-c level within the normal range had an increased cumulative incidence rate of NAFLD in non-obese individuals.

Conclusions

NAFLD is prevalent in the non-obese Chinese population. Furthermore, this is the first study to demonstrate that increased normal LDL-c levels are independently associated with an elevated risk of NAFLD in non-obese individuals.

To examine how general practitioners (GPs) in the UK and GPs in Australia explain their prostate-specific antigen (PSA) testing practices and to illuminate how these explanations are similar and how they are different.

Design

A grounded theory study.

Setting

Primary care practices in Australia and the UK.

Participants

69 GPs in Australia (n=40) and the UK (n=29). We included GPs of varying ages, sex, clinical experience and patient populations. All GPs interested in participating in the study were included.

Results

GPs' accounts revealed fundamental differences in whether and how prostate cancer screening occurred in their practice and in the broader context within which they operate. The history of prostate screening policy, organisational structures and funding models appeared to drive more prostate screening in Australia and less in the UK. In Australia, screening processes and decisions were mostly at the discretion of individual clinicians, and varied considerably, whereas the accounts of UK GPs clearly reflected a consistent, organisationally embedded approach based on local evidence-based recommendations to discourage screening.

Conclusions

The GP accounts suggested that healthcare systems, including historical and current organisational and funding structures and rules, collectively contribute to how and why clinicians use the PSA test and play a significant role in creating the mindlines that GPs employ in their clinic. Australia's recently released consensus guidelines may support more streamlined and consistent care. However, if GP mindlines and thus routine practice in Australia are to shift, to ultimately reduce unnecessary or harmful prostate screening, it is likely that other important drivers at all levels of the screening process will need to be addressed.

Cardiovascular autonomic neuropathy (CAN) and abnormal circadian blood pressure (BP) rhythm are independent cardiovascular risk factors in patients with diabetes and associations between CAN, non-dipping of nocturnal BP and coronary artery disease have been demonstrated. We aimed to test if bedtime dosing (BD) versus morning dosing (MD) of the ACE inhibitor enalapril would affect the 24-hour BP profile in patients with type 1 diabetes (T1D), CAN and non-dipping.

Setting

Secondary healthcare unit in Copenhagen, Denmark.

Participants

24 normoalbuminuric patients with T1D with CAN and non-dipping were included, consisting of mixed gender and Caucasian origin. Mean±SD age, glycosylated haemoglobin and diabetes duration were 60±7 years, 7.9±0.7% (62±7 mmol/mol) and 36±11 years.

Interventions

In this randomised, placebo-controlled, double-blind cross-over study, the patients were treated for 12 weeks with either MD (20 mg enalapril in the morning and placebo at bedtime) or BD (placebo in the morning and 20 mg enalapril at bedtime), followed by 12 weeks of switched treatment regimen.

Primary and secondary outcome measures

Primary outcome was altered dipping of nocturnal BP. Secondary outcomes included a measurable effect on other cardiovascular risk factors than BP, including left ventricular function (LVF).

Results

Systolic BP dipping increased 2.4% (0.03–4.9%; p=0.048) with BD compared to MD of enalapril. There was no increase in mean arterial pressure dipping (2.2% (–0.1% to 4.5%; p=0.07)). No difference was found on measures of LVF (p≥0.15). No adverse events were registered during the study.

Conclusions

We demonstrated that patients with T1D with CAN and non-dipping can be treated with an ACE inhibitor at night as BD as opposed to MD increased BP dipping, thereby diminishing the abnormal BP profile. The potentially beneficial effect on long-term cardiovascular risk remains to be determined.

Studies evaluating caffeine intake during pregnancy and long-term outcomes, such as the child's neurobehaviour, are still scarce and their results are inconsistent. The objective of the present study was to evaluate the association between maternal consumption of caffeine during pregnancy and attention deficit hyperactivity disorder (ADHD) at the age of 11 years.

Methodology

All children born in the city of Pelotas, Brazil, during the year 2004, were selected for a cohort study. The mothers were interviewed at birth to obtain information on coffee and yerba mate consumption during pregnancy, among other matters. At the age of 11 years, presence of ADHD was evaluated using the Development and Well-Being Assessment (DAWBA) questionnaire, applied to the mothers. The prevalence of ADHD was calculated, with 95% CIs. The association between caffeine consumption and ADHD was tested by means of logistic regression.

Results

3485 children were included in the analyses. The prevalence of ADHD was 4.1% (95% CI 3.4% to 4.7%): 5.8% (95% CI 4.7% to 6.9%) among boys and 2.3% (95% CI 1.5% to 3.0%) among girls. The prevalence of caffeine consumption during the entire pregnancy and in the first, second and third trimesters was 88.7% (87.7% to 89.7%), 86.5% (85.4% to 87.5%), 83.0% (81.8% to 84.2%) and 92.3% (91.4% to 93.1%), respectively. Caffeine consumption during the entire pregnancy and the first, second and third trimesters were not associated with ADHD in the crude or adjusted analysis.

Conclusions

The present study did not show any association between maternal caffeine consumption during pregnancy and ADHD at the age of 11 years.

To determine the prevalence and quality of antipsychotic prescribing for people with intellectual disability (ID).

Design

A clinical audit of prescribing practice in the context of a quality improvement programme. Practice standards for audit were derived from relevant, evidence-based guidelines, including NICE. Data were mainly collected from the clinical records, but to determine the clinical rationale for using antipsychotic medication in individual cases, prescribers could also be directly questioned.

Settings

54 mental health services in the UK, which were predominantly NHS Trusts.

Participants

Information on prescribing was collected for 5654 people with ID.

Results

Almost two-thirds (64%) of the total sample was prescribed antipsychotic medication, of whom almost half (49%) had a schizophrenia spectrum or affective disorder diagnosis, while a further third (36%) exhibited behaviours recognised by NICE as potentially legitimate targets for such treatment such as violence, aggression or self-injury. With respect to screening for potential side effects within the past year, 41% had a documented measure of body weight (range across participating services 18–100%), 32% blood pressure (0–100%) and 37% blood glucose and blood lipids (0–100%).

Conclusions

These data from mental health services across the UK suggest that antipsychotic medications are not widely used outside of licensed and/or evidence-based indications in people with ID. However, screening for side effects in those patients on continuing antipsychotic medication was inconsistent across the participating services and the possibility that a small number of these services failed to meet basic standards of care cannot be excluded.

To review systematically the evidence of age-related macular degeneration (AMD) affecting real-world visual ability and quality of life (QoL). To explore trends in specific topics within this body of the literature.

Design

Systematic review.

Methods

A systematic literature search was carried out using MEDLINE, EMBASE, CINAHL, PsycINFO, PsychARTICLES and Health and Psychosocial Instruments for articles published up to January 2015 for studies including people diagnosed with AMD, assessing real-world visual ability or QoL as an outcome. Two researchers screened studies for eligibility. Details of eligible studies including study design, characteristics of study population and outcomes measured were recorded in a data extraction table. All included studies underwent quality appraisal using the Mixed Methods Appraisal Tool 2011 Version (MMAT).

Results

From 5284 studies, 123 were eligible for inclusion. A range of approaches were identified, including performance-based methods, quantitative and qualitative patient-reported outcome measures (PROMs). AMD negatively affects tasks including mobility, face recognition, perception of scenes, computer use, meal preparation, shopping, cleaning, watching TV, reading, driving and, in some cases, self-care. There is evidence for higher rates of depression among people with AMD than among community dwelling elderly. A number of adaptation strategies have been associated with AMD of varying duration. Much of the research fails to report the type of AMD studied (59% of included studies) or the duration of disease in participants (74%). Of those that do report type studied, the breakdown is as follows: wet AMD 20%, dry AMD 4% and both types 17%.

Conclusions

There are many publications highlighting the negative effects of AMD in various domains of life. Future research should focus on delivering some of this research knowledge into patient management and clinical trials and differentiating between the types of AMD.

To translate and validate the Cancer-Related Fatigue (CRF) Scale in the Greek language.

Design

A cross-sectional descriptive design was used in order to translate and validate the CRF Scale in Greek. Factor analyses were performed to understand the psychometric properties of the scale and to establish construct, criterion and convergent validity.

Setting

Outpatients' oncology clinics of two public hospitals in Cyprus.

Participants

148 patients with advanced prostate cancer undergoing chemotherapy.

Results

The Cancer Fatigue Scale (CFS) had good stability (test–retest reliability r=0.79, p<0.001) and good internal consistency (Cronbach's α coefficient for all 15 items α=0.916). Furthermore, the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO value) was found to be 0.743 and considered to be satisfactory (>0.5). The correlations between the CFS physical scale (CFS-FS scale) and the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 physical subscales were found to be significant (r=–0.715). The same occurred between CFS cognitive and EORTC cognitive subscale (r=–0.579). Overall, the criterion validity was verified. The same occurs for the convergent validity of the CFS since all correlations with the Global Health Status (q29–q30) were found to be significant.

Conclusions

This is the first validation study of the CRF Scale in Greek and warrant of its use in the assessment of prostate cancer patient's related fatigue. However, further testing and validation is needed in the early stages of the disease and in patients in later chemotherapy cycles.

A descriptive narrative of preferences for format suggested patients prefer textual as opposed to numerical benefit information. Significant barriers to the acceptance of numerical benefit information included difficulty in understanding the numbers. Patients overestimated the benefits of statins and expressed surprise at the numerical information.

Conclusions

Textual information was preferred but numerical information, in particular in the form of a natural frequency, may help patients make judgements about their medicines. NNTs were found to be very difficult to understand. This raises the prospect that some patients might reject medicines because of disappointment with the perceived low benefits of their medicines. The self-reported impact on behaviour appeared minimal with reports of intentions to ‘do what the doctor tells me’. Further research is needed to explore the impact of such statements on people who are yet to be prescribed a statin.

The relationship between pre-pregnancy body mass index (BMI) and low glucose challenge test (GCT) results by maternal weight status has not been examined. This study aimed to clarify the relationship between a low GCT result and small for gestational age (SGA) by maternal weight status.

Design

A retrospective cohort study in 2 hospitals.

Setting

This study evaluated the obstetric records of women who delivered in a general community hospital and a tertiary perinatal care centre.

Participants

The number of women who delivered in both hospitals between January 2012 and December 2013 and underwent GCT between 24 and 28 weeks of gestation was 2140. Participants with gestational diabetes mellitus or diabetes during pregnancy, and GCT results of ≥140 mg/dL were excluded. Finally, 1860 women were included in the study.

Primary and secondary outcome measures

The participants were divided into low-GCT (≤90 mg/dL) and non-low-GCT groups (91–139 mg/dL). The 2 tests and multivariate logistic regression analyses were conducted to investigate the association between low GCT results and SGA by maternal weight status.

Results

The incidence of SGA was 11.4% (212/1860), and 17.7% (330/1860) of the women showed low GCT results. The patients were divided into 3 groups according to their BMI (underweight, normal weight and obese). When the patients were analysed separately by their weight status after controlling for maternal age, pre-pregnancy maternal weight, maternal weight gain during pregnancy, pregnancy-induced hypertension, thyroid disease and difference in hospital, low GCT results were significantly associated with SGA (OR 2.10; 95% CI 1.14 to 3.89; p=0.02) in the underweight group.

Conclusions

Low GCT result was associated with SGA at birth among underweight women. Examination of maternal glucose tolerance and fetal growth is necessary in future investigations.

Investigate the work–life balance of doctors in training in the UK from the perspectives of trainers and trainees.

Design

Qualitative semistructured focus groups and interviews with trainees and trainers.

Setting

Postgraduate medical training in London, Yorkshire and Humber, Kent, Surrey and Sussex, and Wales during the junior doctor contract dispute at the end of 2015. Part of a larger General Medical Council study about the fairness of postgraduate medical training.

Postgraduate training was characterised by work–life imbalance. Long hours at work were typically supplemented with revision and completion of the e-portfolio. Trainees regularly moved workplaces which could disrupt their personal lives and sometimes led to separation from friends and family. This made it challenging to cope with personal pressures, the stresses of which could then impinge on learning and training, while also leaving trainees with a lack of social support outside work to buffer against the considerable stresses of training. Low morale and harm to well-being resulted in some trainees feeling dehumanised. Work–life imbalance was particularly severe for those with children and especially women who faced a lack of less-than-full-time positions and discriminatory attitudes. Female trainees frequently talked about having to choose a specialty they felt was more conducive to a work–life balance such as General Practice. The proposed junior doctor contract was felt to exacerbate existing problems.

Conclusions

A lack of work–life balance in postgraduate medical training negatively impacted on trainees' learning and well-being. Women with children were particularly affected, suggesting this group would benefit the greatest from changes to improve the work–life balance of trainees.

To determine the prevalence of knee pain among 3 major ethnic groups in Malaysia. By identifying high-risk groups, preventive measures can be targeted at these populations.

Design and setting

A cross-sectional survey was carried out in rural and urban areas in a state in Malaysia. Secondary schools were randomly selected and used as sampling units.

Participants

Adults aged ≥18 years old were invited to answer a self-administered questionnaire on pain experienced over the previous 6 months. Out of 9300 questionnaires distributed, 5206 were returned and 150 participants who did not fall into the 3 ethnic groups were excluded, yielding a total of 5056 questionnaires for analysis. 58.2% (n=2926) were women. 50% (n=2512) were Malays, 41.4% (n=2079) were Chinese and 8.6% (n=434) were Indians.

Results

21.1% (n=1069) had knee pain during the previous 6 months. More Indians (31.8%) experienced knee pain compared with Malays (24.3%) and Chinese (15%) (p<0.001). The odds of Indian women reporting knee pain was twofold higher compared with Malay women. There was a rising trend in the prevalence of knee pain with increasing age (p<0.001). The association between age and knee pain appeared to be stronger in women than men. 68.1% of Indians used analgesia for knee pain while 75.4% of Malays and 52.1% of Chinese did so (p<0.001). The most common analgesic used for knee pain across all groups was topical medicated oil (43.7%).

Conclusions

The prevalence of knee pain in adults was more common in Indian women and older women age groups and Chinese men had the lowest prevalence of knee pain. Further studies should investigate the reasons for these differences.

To compare the prevalence of common mental disorders (CMDs) derived from data held in primary care records with that measured using the revised Clinical Interview Schedule (CIS-R) in order to assess the potential robustness of findings based only on routinely collected data.

Design and setting

Comparison study using linkage between the Avon Longitudinal Study of Parents and Children (ALSPAC) and electronic primary care records.

Participants

We studied 1562 adolescents who had completed the CIS-R in ALSPAC at age 17–18 years and had linkage established to their primary care records.

Outcome measures

Outcome measures from ALSPAC were whether or not an individual met International Classification of Diseases-10 criteria for a diagnosis of (1) a CMD or, specifically, (2) depression. Lists of Read codes corresponding to diagnoses, symptoms and treatments were used to create 12 definitions of CMD and depression alone using the primary care data. We calculated sensitivities and specificities of these, using CIS-R definitions as the reference standard.

Results

Sensitivities ranged from 5.2% to 24.3% for depression and from 3.8% to 19.2% for CMD. The specificities of all definitions were above 98% for depression and above 96% for CMD.

For both outcomes, the definition that included current diagnosis, treatment or symptoms identified the highest proportion of CIS-R cases.

Conclusions

Most individuals meeting case definitions for CMD based on primary care data also met CIS-R case definitions. Conversely many individuals identified as cases using the CIS-R had no evidence of CMD in their clinical records. This suggests that clinical databases are likely to yield underestimates of the burden of CMD in the population. However, clinical records appear to yield valid diagnoses which may be useful for studying risk factors and consequences of CMD. The greatest epidemiological value may be obtained when information is available from survey and clinical records.

The current study was undertaken for use of the decision tree (DT) method for development of different prediction models for incidence of type 2 diabetes (T2D) and for exploring interactions between predictor variables in those models.

Design

Prospective cohort study.

Setting

Tehran Lipid and Glucose Study (TLGS).

Methods

A total of 6647 participants (43.4% men) aged >20 years, without T2D at baselines ((1999–2001) and (2002–2005)), were followed until 2012. 2 series of models (with and without 2-hour postchallenge plasma glucose (2h-PCPG)) were developed using 3 types of DT algorithms. The performances of the models were assessed using sensitivity, specificity, area under the ROC curve (AUC), geometric mean (G-Mean) and F-Measure.

Primary outcome measure

T2D was primary outcome which defined if fasting plasma glucose (FPG) was ≥7 mmol/L or if the 2h-PCPG was ≥11.1 mmol/L or if the participant was taking antidiabetic medication.

Results

During a median follow-up of 9.5 years, 729 new cases of T2D were identified. The Quick Unbiased Efficient Statistical Tree (QUEST) algorithm had the highest sensitivity and G-Mean among all the models for men and women. The models that included 2h-PCPG had sensitivity and G-Mean of (78% and 0.75%) and (78% and 0.78%) for men and women, respectively. Both models achieved good discrimination power with AUC above 0.78. FPG, 2h-PCPG, waist-to-height ratio (WHtR) and mean arterial blood pressure (MAP) were the most important factors to incidence of T2D in both genders. Among men, those with an FPG≤4.9 mmol/L and 2h-PCPG≤7.7 mmol/L had the lowest risk, and those with an FPG>5.3 mmol/L and 2h-PCPG>4.4 mmol/L had the highest risk for T2D incidence. In women, those with an FPG≤5.2 mmol/L and WHtR≤0.55 had the lowest risk, and those with an FPG>5.2 mmol/L and WHtR>0.56 had the highest risk for T2D incidence.

Conclusions

Our study emphasises the utility of DT for exploring interactions between predictor variables.

Following publication of the guidelines, the proportion of drinkers aware of guidelines did not increase from its baseline level of 85.1% (CI 82.7% to 87.1%). However, the proportion of male drinkers saying the guideline was 14 units or less increased from 22.6% (CI 18.9% to 26.7%) in December to 43.3% (CI 38.9% to 47.8%) in January and was at 35.6% (CI 31.6% to 39.9%) in May. Last month exposure to the guidelines was below 25% in all locations except television/radio where exposure increased from 33% (CI 28.8% to 36.2%) in December to 65% (CI 61.2% to 68.3%) in January. Awareness and knowledge of guidelines was lowest in social grade DE and this gap remained after publication.

Conclusions

Publication of new or revised lower risk drinking guidelines can improve drinkers’ knowledge of these guidelines within all sociodemographic groups; however, in the absence of sustained promotional activity, positive effects may not be maintained and social inequalities in awareness and knowledge of guidelines are likely to persist.

Most GPs (87%) reported that they were likely to routinely ask patients about their alcohol consumption and had sufficient skills to manage alcohol issues (74%). Potential barriers to enquiring about alcohol included perceptions that patients are not always honest about alcohol intake (84%) and communication difficulties (44%). ‘I usually ask about alcohol’ was ranked by 36% as the number one presentation likely to prompt alcohol discussion. Altered liver function test results followed by suspected clinical depression were most frequently ranked in the top three presentations. Suspicious or frequent injuries, frequent requests for sickness certificates and long-term unemployment were ranked in the top three presentations by 20% or less. Confidence in managing alcohol issues independently predicted likelihood to ‘routinely ask’ about alcohol consumption. Lack of time emerged as the single most important barrier to routinely asking about alcohol. Lack of time was predicted by perceptions of competing health issues in patients, fear of eliciting negative responses and lower confidence in ability to manage alcohol-related issues.

This paper aims to assess the socioeconomic determinants of a high 10 year cardiovascular risk in Tunisia.

Setting

We used a national population based cross sectional survey conducted in 2005 in Tunisia comprising 7780 subjects. We applied the non-laboratory version of the Framingham equation to estimate the 10 year cardiovascular risk.

Participants

8007 participants, aged 35–74 years, were included in the sample but effective exclusion of individuals with cardiovascular diseases and cancer resulted in 7780 subjects (3326 men and 4454 women) included in the analysis.

Results

Mean age was 48.7 years. Women accounted for 50.5% of participants. According to the Framingham equation, 18.1% (17.25–18.9%) of the study population had a high risk (≥20% within 10 years). The gender difference was striking and statistically significant: 27.2% (25.7–28.7%) of men had a high risk, threefold higher than women (9.7%; 8.8–10.5%). A higher 10 year global cardiovascular risk was associated with social disadvantage in men and women; thus illiterate and divorced individuals, and adults without a professional activity had a significantly higher risk of developing a cardiovascular event in 10 years. Illiterate men were at higher risk than those with secondary and higher education (OR=7.01; 5.49 to 9.14). The risk in illiterate women was more elevated (OR=13.57; 7.58 to 24.31). Those living in an urban area had a higher risk (OR=1.45 (1.19 to 1.76) in men and OR=1.71 (1.35 to 2.18) in women).

Conclusions

The 10 year global cardiovascular risk in the Tunisian population is already substantially high, affecting almost a third of men and 1 in 10 women, and concentrated in those more socially disadvantaged.

In 2010, the 13-valent pneumococcal conjugate vaccine (PCV-13) replaced the 7-valent vaccine (introduced in 2006) for vaccination against invasive pneumococcal diseases (IPDs), pneumonia and acute otitis media (AOM) in the UK. Using recent evidence on the impact of PCVs and epidemiological changes in the UK, we performed a cost-effectiveness analysis (CEA) to compare the pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) with PCV-13 in the ongoing national vaccination programme.

Design

CEA was based on a published Markov model. The base-case scenario accounted only for direct medical costs. Work days lost were considered in alternative scenarios.

Setting

Calculations were based on serotype and disease-specific vaccine efficacies, serotype distributions and UK incidence rates and medical costs.

Population

Health benefits and costs related to IPD, pneumonia and AOM were accumulated over the lifetime of a UK birth cohort.

Interventions

Vaccination of infants at 2, 4 and 12 months with PHiD-CV or PCV-13, assuming complete coverage and adherence.

Outcome measures

The incremental cost-effectiveness ratio (ICER) was computed by dividing the difference in costs between the programmes by the difference in quality-adjusted life-years (QALY).

Results

Under our model assumptions, both vaccines had a similar impact on IPD and pneumonia, but PHiD-CV generated a greater reduction in AOM cases (161 918), AOM-related general practitioner consultations (31 070) and tympanostomy tube placements (2399). At price parity, PHiD-CV vaccination was dominant over PCV-13, saving 734 QALYs as well as £3.68 million to the National Health Service (NHS). At the lower list price of PHiD-CV, the cost-savings would increase to £45.77 million.

Conclusions

This model projected that PHiD-CV would provide both incremental health benefits and cost-savings compared with PCV-13 at price parity. Using PHiD-CV could result in substantial budget savings to the NHS. These savings could be used to implement other life-saving interventions.

We compared the effectiveness of diabetes-focused messaging strategies at increasing enrolment in a healthy food programme among adults with diabetes.

Methods

Vitality is a multifaceted wellness benefit available to members of Discovery Health, a South Africa-based health insurer. One of the largest Vitality programmes is HealthyFood (HF), an incentive-based programme designed to encourage healthier diets by providing up to 25% cashback on healthy food purchases. We randomised adults with type 2 diabetes to 1 of 5 arms: (1) control, (2) a diabetes-specific message, (3) a message with a recommendation of HF written from the perspective of a HF member with diabetes, (4) a message containing a physician's recommendation of HF, or (5) the diabetes-specific message from arm 2 paired with an ‘enhanced active choice’(EAC). In an EAC, readers are asked to make an immediate choice (in this case, to enrol or not enrol); the pros and cons associated with the preferred and non-preferred options are highlighted. HF enrolment was assessed 1 month following the first emailed message.

Results

We randomised 3906 members. After excluding those who enrolled in HF or departed from the Vitality programme before the first intervention email, 3665 (94%) were included in a modified intent-to-treat analysis. All 4 experimental arms had significantly higher HF enrolment rates compared with control (p<0.0001 for all comparisons). When comparing experimental arms, the diabetes-specific message with the EAC had a significantly higher enrolment rate (12.6%) than the diabetes-specific message alone (7.6%, p=0.0016).

Conclusions

Messages focused on diabetes were effective at increasing enrolment in a healthy food programme. The addition of a framed active choice to a message significantly raised enrolment rates in this population. These findings suggest that simple, low-cost interventions can enhance enrolment in health promoting programmes and also be pragmatically tested within those programmes.

In this large volunteer study, some commonly prescribed medications were associated with poor cognitive performance. Some associations may reflect underlying diseases for which the medications were prescribed, although the analysis controlled for the possible effect of diagnosis. Other drugs, whose association cannot be linked to the effect of any disease, may need vigilance for their implications in clinical practice.

Updated knowledge on the validity of self-reported myocardial infarction (SMI) and self-reported stroke (SRS) is needed in Norway. Our objective was to compare questionnaire data and hospital discharge data from regions with Sami and Norwegian populations to assess the validity of these outcomes by ethnicity, sex, age and education.

16 865 men and women aged 30 and 36–79 years participated in the Population-based Study on Health and Living Conditions in Sami and Norwegian Populations (SAMINOR) 1 Survey in 2003–2004. Information on SMI and SRS was available from self-administered questionnaires for 15 005 and 15 088 of these participants, respectively. We compared this information with hospital discharge data from 1994 until SAMINOR 1 Survey attendance.

The sensitivity and PPV of SMI were 90.1% and 78.9%, respectively; the PPV increased to 93.1% when all ischaemic heart disease (IHD) diagnoses were included. The SMI prevalence estimate was 2.3% and hospital-based 2.0%. The sensitivity and PPV of SRS were 81.1% and 64.3%, respectively. The SRS prevalence estimate was 1.5% and hospitalisation-based 1.2%. Moderate to no variation was observed in validity according to ethnicity, sex, age and education.

Conclusions

The sensitivity and PPV of SMI were high and moderate, respectively; for SRS, both of these measures were moderate. Our results show that SMI from the SAMINOR 1 Survey may be used in aetiological/analytical studies in this population due to a high IHD-specific PPV. The SAMINOR 1 questionnaire may also be used to estimate the prevalence of acute myocardial infarction and acute stroke.

To determine if a targeted and tailored intervention based on a discussion informed by validated adherence scales will improve medication adherence.

Design

Prospective randomised trial.

Setting

2 community pharmacies in Brisbane, Australia.

Methods

Patients recently initiated on a cardiovascular or oral hypoglycaemic medication within the past 4–12 weeks were recruited from two community pharmacies. Participants identified as non-adherent using the Medication Adherence Questionnaire (MAQ) were randomised into the intervention or control group. The intervention group received a tailored intervention based on a discussion informed by responses to the MAQ, Beliefs about Medicines Questionnaire-Specific and Brief Illness Perception Questionnaire. Adherence was measured using the MAQ at 3 and 6 months following the intervention.

Results

A total of 408 patients were assessed for eligibility, from which 152 participants were enrolled into the study. 120 participants were identified as non-adherent using the MAQ and randomised to the ‘intervention’ or ‘control’ group. The mean MAQ score at baseline in the intervention and control were similar (1.58: 95% CI (1.38 to 1.78) and 1.60: 95% CI (1.43 to 1.77), respectively). There was a statistically significant improvement in adherence in the intervention group compared to control at 3 months (mean MAQ score 0.42: 95% CI (0.27 to 0.57) vs 1.58: 95% CI (1.42 to 1.75); p<0.001). The significant improvement in MAQ score in the intervention group compared to control was sustained at 6 months (0.48: 95% CI (0.31 to 0.65) vs 1.48: 95% CI (1.27 to 1.69); p<0.001).

Conclusions

An intervention that targeted non-adherent participants and tailored to participant-specific reasons for non-adherence was successful at improving medication adherence.

General practitioners (GPs) play a key role in heart failure (HF) management. Despite multiple guidelines, the management of patients with HF in primary care is suboptimal. Therefore, all the qualitative evidence concerning GPs’ perceptions of managing HF in primary care was synthesised to identify barriers and facilitators for optimal care, and ideas for improvement.

Design

Qualitative evidence synthesis.

Methods

Searches of MEDLINE, EMBASE, Web of Science and CINAHL databases up to 20/12/2015 were conducted. The Critical Appraisal Skills Programme's checklist for qualitative research was used for quality assessment. Thematic analysis was used as method of analysis.

Results

Of 5427 articles, 18 qualitative articles were included. Findings were organised in HF-specific factors, patient factors, physician factors and contextual factors. GPs’ uncertainty in all areas of HF management was highlighted. HF management started with an uncertain diagnosis, leading to difficulties with communication, treatment and advance care planning. Lack of access to specialised care and lack of knowledge were identified as important contributors to this uncertainty. In an effort to overcome this, strategies bringing evidence into practice should be promoted. GPs expressed the need for a multidisciplinary chronic care approach for HF. However, mixed experiences were noted with regard to interprofessional collaboration.

Conclusions

The main challenges identified in this synthesis were how to deal with GPs’ uncertainty about clinical practice, how to bring evidence into practice and how to work together as a multiprofessional team. These barriers were situated predominantly on the physician and contextual level. Targets to improve GPs’ HF care were identified.

In the quantitative phase, 79% of the 105 GPs already treated HP. Most of the difficulties they encountered while treating HP concerned social matters (mean level of perceived difficulties=3.95/5, IC 95 (3.74 to 4.17)), lack of medical information (mn=3.78/5, IC 95 (3.55 to 4.01)) patient's compliance (mn=3.67/5, IC 95 (3.45 to 3.89)), loneliness in practice (mn=3.45/5, IC 95 (3.18 to 3.72)) and time required for the doctor (mn=3.25, IC 95 (3 to 3.5)). From qualitative analysis we understood that maintaining a stable follow-up was a major condition for GPs to contribute effectively to the care of HP. Acting on health system organisation, developing a medical and psychosocial approach with closer relation with social workers and enhancing the collaboration between tailored and non-tailored programmes were also other key answers.

Conclusions

If we adapt the conditions of GPs practice, they could contribute to the improvement of HP's health. These results will enable the construction of a new model of primary care organisation aiming to improve access to healthcare for HP.

To examine feasibility, qualitative feedback and satisfaction associated with a 4-session introduction to Tai Chi for veterans with post-traumatic stress symptoms.

Design

We observed and reported recruitment and retention rates, participant characteristics, adherence, and satisfaction across 2 cohorts. We also examined qualitative feedback provided by questionnaires, focus groups and individual interviews.

Main outcome measures

Rates of recruitment and retention, focus group and individual feedback interviews, self-reported satisfaction.

Participants

17 veterans with post-traumatic stress symptoms.

Results

Almost 90% (17/19) of those eligible following the telephone screen enrolled in the programme. Three-quarters (76.4%) of the participants attended at least 3 of the 4 Tai Chi sessions. Qualitative data analysis revealed themes indicating favourable impressions of the Tai Chi sessions. In addition, participants reported feeling very engaged during the sessions, and found Tai Chi to be helpful for managing distressing symptoms (ie, intrusive thoughts, concentration difficulties, physiological arousal). Participants also reported high satisfaction: 93.8% endorsed being very or mostly satisfied with the programme. All participants (100%) indicated that they would like to participate in future Tai Chi programmes and would recommend it to a friend.

Conclusions

Tai Chi appears to be feasible and safe for veterans with symptoms of post-traumatic stress disorder (PTSD), is perceived to be beneficial and is associated with high rates of satisfaction. This study highlights the need for future investigation of Tai Chi as a novel intervention to address symptoms of PTSD.

To investigate an association between ideal cardiovascular health metrics (CVH) and the risk of developing end-stage renal disease (ESRD).

Setting

Community of Kailuan in Tangshan/China.

Participants

We examined in a community-based longitudinal cohort study 91 443 participants without history of stroke or myocardial infarction at baseline in 2006–2007, with a glomerular filtration rate (GFR) ≥15 mL/min at baseline, and who participated in at least 1 of 3 follow-up examinations in 2008–2009, 2010–2011 and 2012–2013.

Incidence of ESRD ranged from 7.06 in the lowest CVH category to 2.34 in the highest CVH category. After adjusting for age, sex, educational level, income, alcohol consumption and GFR, the lowest CVH category as compared with the highest CVH category had a significantly higher risk of incident ESRD (adjusted HR 2.87; 95% CI 1.53 to 5.39). For every decrease in group number of the cum-CVH score, the risk of ESRD increased by 20% (HR 1.20; 95% CI 1.13 to 1.28). The effect was consistent across sex and all age groups.

Conclusions

A low CVH score significantly increased the risk of incident ESRD. Risk factors for cardiovascular events may also be associated with an increased risk for kidney failure.

Our study examines differences in eating behaviour between day workers and rotating shift workers, and considers whether diurnal preference could explain the differences.

Methods

Japanese female nurses were studied (39 day workers and 123 rotating shift workers, aged 21–63 years) using self-administered questionnaires. The questionnaires assessed eating behaviours, diurnal preference and demographic characteristics. The questionnaire in the Guidelines for the management of obesity disease issued by the Japan Society for the Study of Obesity was used to obtain scores for the levels of obesity-related eating behaviours, including cognition of constitution, motivation for eating, eating as a diversion, feeling of satiety, eating style, meal contents and temporal eating patterns. The Japanese version of the Morningness–Eveningness (ME) questionnaire was used to measure self-rated preference for the degree to which people prefer to be active in the morning or the evening (ME).

Results

The scores for meal contents and temporal eating patterns in rotating shift workers were significantly higher than those in day workers. The ME score of rotating shift workers was significantly lower, indicating greater eveningness/less morningness among rotating shift workers. Multivariate linear regression revealed that the ME score was significantly negatively associated with temporal eating patterns and showed a negative association with the score for meal contents at a trend level, while current work shift was not significantly correlated with the scores.

Conclusions

These results suggest that eating behaviours for rotating shift workers are associated with a more unbalanced diet and abnormal temporal eating patterns and that the associations may be explained by diurnal preference rather than by rotating shift work.

Sleep disorders are prevalent medical disorders in patients with rheumatoid arthritis (RA). However, whether patients with RA are at an increased risk of developing obstructive sleep apnoea (OSA) is unclear.

Design

Using population-based retrospective cohort study to examine the risk of OSA in patients with RA.

Setting

We used claims data of the National Health Insurance Research Database (NHIRD) of Taiwan.

Participants

We identified a RA cohort with 33 418 patients newly diagnosed in 2000–2010 and a randomly selected non-RA comparison cohort with 33 418 individuals frequency matched by sex, age and diagnosis year.

Primary and secondary outcome measures

Incident OSA was estimated by the end of 2011. The HRs of OSA were calculated using the Cox proportional hazards regression analysis.

Results

The overall incidence rate of OSA was 75% greater in the RA cohort than in the non-RA cohort (3.04 vs 1.73/10 000 person-years, p<0.001), with an adjusted HR (aHR) of 1.75 (95% CI 1.18 to 2.60). Stratified analyses by sex, age group and comorbidity revealed that the incidence rates of OSA associated with RA were higher in all subgroups.

Conclusions

This population-based retrospective cohort study suggested that patients with RA should be monitored for the risk of developing OSA.

To study the changes in prevalence, characteristics and outcomes of pregnant smokers over time and legislative changes.

Design and setting

Retrospective nationwide cohort.

Participants

Our study consisted of 9627 randomly selected pregnancies from the Finnish Maternity Cohort (1987–2011), with demographic characteristics and pregnancy and perinatal data obtained from the Medical Birth Registry and early pregnancy serum samples analysed for cotinine levels. Women were categorised based on their self-reported smoking status and measured cotinine levels (with ≥4.73 ng/mL deemed high). Data were stratified to three time periods based on legislative changes in the Tobacco Act.

Primary and secondary outcome measures

Prevalence of pregnant smokers and demographics, and perinatal and pregnancy outcomes of pregnant smokers over time.

Results

Overall, 71.6% of women were non-smokers, 16.2% were active cigarette smokers, 7.7% undisclosed smoking but had high cotinine levels and 4.5% were inactive cigarette smokers. The prevalence of active cigarette smokers decreased from mid-1990s onwards among women aged ≥30 years, probably due to the ban of cigarette smoking in most workplaces. We observed no changes in the prevalence of inactive smokers or women who undisclosed smoking by time or legislative changes.

Women who undisclosed smoking had similar characteristics and perinatal outcomes as inactive and active smokers. Compared with non-smokers, women who undisclosed smoking were more likely to be young, unmarried, have a socioeconomic status lower than white-collar worker and have a preterm birth.

Conclusions

Women who undisclosed smoking were very similar to pregnant cigarette smokers. We observed a reduction in the prevalence of active pregnant cigarette smokers after the ban of indoor smoking in workplaces and restaurants, mostly among women aged ≥30 years.

Cancer-associated thrombosis (CAT) complex condition, which may present to any healthcare professional and at any point during the cancer journey. As such, patients may be managed by a number of specialties, resulting in inconsistent practice and suboptimal care. We describe the development of a dedicated CAT service and its evaluation.

Setting

Specialist cancer centre, district general hospital and primary care.

Participants

Patients with CAT and their referring clinicians.

Intervention

A cross specialty team developed a dedicated CAT service , including clear referral pathways, consistent access to medicines, patient's information and a specialist clinic.

Primary and secondary outcome measures

The service was evaluated using a mixed-methods evaluation , including audits of clinical practice, clinical outcomes, staff surveys and qualitative interviewing of patients and healthcare professionals.

Results

Data from 457 consecutive referrals over an 18-month period were evaluated. The CAT service has led to an 88% increase in safe and consistent community prescribing of low-molecular-weight heparin, with improved access to specialist advice and information. Patients reported improved understanding of their condition, enabling better self-management as well as better access to support and information. Referring clinicians reported better care standards for their patients with improved access to expertise and appropriate management.

Conclusions

A dedicated CAT service improves overall standards of care and is viewed positively by patients and clinicians alike. Further health economic evaluation would enhance the case for establishing this as the standard model of care.

Fertility services in the UK are offered by over 200 Human Fertilisation and Embryology Authority (HFEA)-registered NHS and private clinics. While in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) form part of the National Institute for Health and Care Excellence (NICE) guidance, many further interventions are offered. We aimed to record claims of benefit for interventions offered by fertility centres via information on the centres' websites and record what evidence was cited for these claims.

Methods

We obtained from HFEA a list of all UK centres providing fertility treatments and examined their websites. We listed fertility interventions offered in addition to standard IVF and ICSI and recorded statements about interventions that claimed or implied improvements in fertility in healthy women. We recorded which claims were quantified, and the evidence cited in support of the claims. Two reviewers extracted data from websites. We accessed websites from 21 December 2015 to 31 March 2016.

Results

We found 233 websites for HFEA-registered fertility treatment centres, of which 152 (65%) were excluded as duplicates or satellite centres, 2 were andrology clinics and 5 were unavailable or under construction websites. In total, 74 fertility centre websites, incorporating 1401 web pages, were examined for claims. We found 276 claims of benefit relating to 41 different fertility interventions made by 60 of the 74 centres (median 3 per website; range 0 to 10). Quantification was given for 79 (29%) of the claims. 16 published references were cited 21 times on 13 of the 74 websites.

Conclusions

Many fertility centres in the UK offer a range of treatments in addition to standard IVF procedures, and for many of these interventions claims of benefit are made. In most cases, the claims are not quantified and evidence is not cited to support the claims. There is a need for more information on interventions to be made available by fertility centres, to support well-informed treatment decisions.

We aimed to assess the nature of association between job stress and occupational injuries among firefighters in Korea.

Design

Cross-sectional study.

Setting

We conducted a nationwide survey using self-reported questionnaires in South Korea.

Participants

A survey was conducted among 30 630 firefighters; 25 616 (83.6%) responded. Our study included firefighters who were 20–59 years old. Individuals with <12 months of current job experience and those with missing data were excluded; ultimately, 14 991 firefighters were analysed.

Results

Among fire suppression personnel, high job demands (OR=1.49, 95% CI 1.25 to 1.77), high interpersonal conflicts (OR=1.18, 95% CI 1.02 to 1.37), a poor organisational system (OR=1.33, 95% CI 1.14 to 1.55), and a negative workplace environment (OR=1.41, 95% CI 1.21 to 1.64) were associated with the occurrence of occupational injury; high job demands (OR=1.22, 95% CI 1.01 to 1.47) were also associated with the frequency of injuries. Among emergency medical services personnel, high job demands (OR=1.26, 95% CI 1.03 to 1.54), high interpersonal conflicts (OR=1.40, 95% CI 1.19 to 1.66), a poor organisational system (OR=1.55, 95% CI 1.30 to 1.85), lack of reward (OR=1.43, 95% CI 1.21 to 1.69) and a negative workplace environment (OR=1.30, 95% CI 1.10 to 1.54) were associated with the occurrence of occupational injury; low job control (OR=1.20, 95% CI 1.04 to 1.38), high interpersonal conflicts (OR=1.18, 95% CI 1.03 to 1.36), lack of reward (OR=1.17, 95% CI 1.02 to 1.35) and a negative workplace climate (OR=1.16, 95% CI 1.01 to 1.34) were also associated with a greater number of injuries. Among officers, high job demands (OR=1.96, 95% CI 1.35 to 2.85) and a negative workplace environment (OR=1.54, 95% CI 1.13 to 2.10) were associated with the occurrence of occupational injuries; however, there was no significant correlation between job stress and the number of injuries.

Conclusions

High job stress among firefighters was associated with both the occurrence of occupational injury, and also with an increased frequency of injuries. Therefore, job stress should be addressed to prevent occupational injuries among firefighters.

Cholera is a major gastroenteric disease with reports on fluctuation and resistance. Hence, the objective is to determine the trend in seasonality, resistance pattern, prevalent biotypes, serotypes and phage types between 2004 and 2013 among Vibrio cholerae isolates.

Design

A retrospective cross-sectional study.

Settings

A single-centre study was carried out at a tertiary care hospital in a metropolitan city (Mumbai) of a developing country (India).

Methods

Records of stool specimen cultures of patients with suspected cholera from January 2004 to December 2013 were analysed. The organisms were identified as per standard protocol. Antimicrobial susceptibility testing was performed as per Clinical Laboratory Standard Institute. Biotyping, serotyping and phage typing were carried out. From the confirmed cases of cholera, demographic and laboratory details were noted. Descriptive analysis was used and the data were presented in the form of percentages.

Results

Vibrio cholerae was predominant in males and was isolated from 9.41% (439/4664) of stool specimens. Variability was found in terms of the gross appearance of stool specimens, seasonal trend and antibiotic resistance pattern. The antimicrobial susceptibility showed a waxing and waning pattern for most of the antibiotics (ampicillin, cefuroxime, chloramphenicol, tetracycline) tested, while for a few others the strains were either uniformly sensitive (gentamicin, norfloxacin) or resistant (trimethoprim-sulfamethoxazole, nalidixic acid). All isolates belonged to subgroup O1 and biotype El Tor. The most common serotype was Ogawa. The predominant phage type was T2 (old scheme) and T27 (new scheme).

Conclusions

The predominant biotype, serotype and phage type were El Tor, Ogawa and T27 phage, respectively. The changing trends in antimicrobial resistance pattern over the years necessitate continued epidemiological and microbiological surveillance of the disease.

Research suggests that individual and environmental resilience protective factors may be associated with adolescent substance use; however, the associations between a broad range of such factors and use of various types of substances have not been examined. The study aimed to determine the association between a comprehensive range of adolescent individual and environmental resilience protective factors and measures of tobacco, alcohol and illicit substance use.

Despite individual relationships between the majority of resilience protective factors and substance use types, the protective benefit of such factors for adolescent substance use was limited to only a small number of such factors when considered collectively. Such results suggest that interventions seeking to reduce adolescent substance use may need to target specific protective factors to address specific types of substance use.

The purpose of this study was to investigate the characteristics of nailfold capillaroscopy associated with hand-arm vibration syndrome (HAVS).

Methods

In total, 113 male gold miners were recruited: 35 workers who were chronically exposed to vibration and developed vibration-induced white finger were defined as the HAVS group, 39 workers who were exposed to vibration but did not have HAVS were classified as the vibration-exposed controls (VEC) group, and 39 workers without vibration exposure were categorised as the non-VEC (NVEC) group. Video capillaroscopy was used to capture images of the 2nd, 3rd and 4th fingers of both hands. The following nailfold capillary characteristics were included: number of capillaries/mm, avascular areas, haemorrhages and enlarged capillaries. The experiments were carried out in the same winter. All characteristics were evaluated under blinded conditions.

Results

Significant differences in all morphological characteristics existed between the groups (p<0.05). Avascular areas in the HAVS, VEC and NVEC groups appeared in 74.3%, 43.6% and 25.0% of participants, respectively. A higher percentage of participants had haemorrhages in the HAVS group (65.7%) compared with the other groups (VEC: 7.7% and NVEC: 7.5%). The number of capillaries/mm, input limb width, output limb width, apical width, and ratio of output limb and input limb all had more than 70% sensitivity or specificity of their cut-off value.

137 participants (96 trainees, 41 trainers) were purposively sampled from a framework comprising: doctors from all stages of training in general practice, medicine, obstetrics and gynaecology, psychiatry, radiology, surgery or foundation, in 4 geographical areas, from white and black and minority ethnic (BME) backgrounds, who qualified in the UK and abroad.

Results

Most trainees described difficult experiences, but BME UK graduates (UKGs) and international medical graduates (IMGs) could face additional difficulties that affected their learning and performance. Relationships with senior doctors were crucial to learning but bias was perceived to make these relationships more problematic for BME UKGs and IMGs. IMGs also had to deal with cultural differences and lack of trust from seniors, often looking to IMG peers for support instead. Workplace-based assessment and recruitment were considered vulnerable to bias whereas examinations were typically considered more rigorous. In a system where success in recruitment and assessments determines where in the country you can get a job, and where work–life balance is often poor, UK BME and international graduates in our sample were more likely to face separation from family and support outside of work, and reported more stress, anxiety or burnout that hindered their learning and performance. A culture in which difficulties are a sign of weakness made seeking support and additional training stigmatising.

Conclusions

BME UKGs and IMGs can face additional difficulties in training which may impede learning and performance. Non-stigmatising interventions should focus on trainee–trainer relationships at work and organisational changes to improve trainees’ ability to seek social support outside work.

Primary outcomes were accelerometer-assessed minutes of moderate to vigorous physical activity (MVPA) per day, accelerometer-assessed minutes of sedentary behaviour per day and reported daily consumption of servings of fruit and vegetables.

Results

60 schools with 2221 eligible children were recruited. As in the previously published assessment immediately after the end of the intervention, none of the three primary outcomes differed between children in schools allocated to the intervention, compared with those in control schools at the end of the long-term follow-up (1 year after the end of the intervention). Differences in secondary outcomes were consistent with those at the immediate follow-up, with no evidence that these had diminished over time. Comparing intervention with control schools, the difference in mean child-reported screen viewing at the weekend was –16.03 min (95% CI –32.82 to 0.73), for servings of snacks per day, the difference was –0.11 (95% CI –0.39 to 0.06), in servings of high-energy drinks per day –0.20 (95% CI –0.39 to –0.01) and in servings of high-fat foods per day –0.12 (95% CI –0.39 to 0.00). None of these reached our predefined level of statistical significance, especially after accounting for multiple testing.

Conclusions

School-based curriculum interventions alone are unlikely to have a major public health impact on children's diet and physical activity.

This systematic review aimed to assess the clinical evidence supporting the use of herbal medicines (HMs) for the treatment of otitis media with effusion (OME).

Design

Systematic review and meta-analysis.

Data sources

MEDLINE, EMBASE, Cochrane Library, AMED, CINAHL and three trial registries were searched up to January 2015. We also searched five Korean medical databases (KoreaMed, RISS, OASIS, DBPIA and KISS) and three Chinese databases (CNKI, Wanfang and VIP).

Study eligibility criteria

This study included randomised clinical trials that reported the effects of HM for OME. The primary outcome was the complete resolution of OME at 2 or 3 months post randomisation. Secondary outcomes included the partial or complete resolution at all possible time points and hearing test. Three authors independently screened the titles and abstracts, selected studies and extracted the data relating to trial quality, characteristics and results.

Results

A total of 2141 potentially relevant studies were identified, of which 17 randomised clinical trials met our inclusion criteria. Most were evaluated as having a high or unclear risk of bias. Tongqiao tablets, Tongqiao huoxue decoctions and Tsumura-Saireito were associated with a lower complete or partial resolution rate when compared with conventional medicines (CMs) (p=0.02, p=0.0001, and p=0.04, respectively), and similar outcomes were observed with Huanglong tonger pills, Erzhang decoctions and Shenling baizhu powder when combined with CM versus CM alone (p<0.00001, p=0.02, and p=0.05, respectively). Tongqiao huoxue decoction plus CM appeared to be more effective than CM in terms of improving the pure tone threshold levels (p=0.0007). Tsumura-Saireito was found to affect the proportion of patients with normalised tympanometry (p=0.03).

Conclusions

Despite some indications of potential symptom improvement, the evidence regarding the effectiveness and efficacy of HMs for OME is of poor quality and therefore inconclusive.

To provide a comprehensive assessment of the management of traumatic brain injury (TBI) relating to epidemiology, complications and standardised mortality across specialist units.

Design

The Trauma Audit and Research Network collects data prospectively on patients suffering trauma across England and Wales. We analysed all data collected on patients with TBI between April 2014 and June 2015.

We identified 15 820 patients with TBI presenting to neurosurgical centres directly (6258), transferred from a district hospital to a neurosurgical centre (3682) and remaining in a district general hospital (5880). The commonest mechanisms of injury were falls in the elderly and road traffic collisions in the young, which were more likely to present in coma. In severe TBI (Glasgow Coma Score (GCS) ≤8), the median time from admission to imaging with CT scan is 0.5 hours. Median time to craniotomy from admission is 2.6 hours and median time to intracranial pressure monitoring is 3 hours. The most frequently documented complication of severe TBI is bronchopneumonia in 5% of patients. Risk-adjusted W scores derived from the Ps14n model indicate that no neurosurgical unit fell outside the 3 SD limits on a funnel plot.

Conclusions

We provide the first comprehensive report of the management of TBI in England and Wales, including data from all neurosurgical units. These data provide transparency and suggests equity of access to high-quality TBI management provided in England and Wales.

Carotid plaque and intima-media thickness are non-invasive arterial markers that are used as surrogate end points for cardiovascular disease. The aim was to assess the prevalence and severity of carotid plaque, and examine its determinant risk factors and their association to the common carotid artery intima-media thickness (CCA-IMT) in a general population.

Methods

We examined 6524 participants aged 25–69 years in the population-based REFINE (Risk Evaluation For INfarct Estimates)-Reykjavik study. Plaques at the bifurcation and internal carotid arteries were evaluated. Mean CCA-IMT was measured in the near and far walls of the common carotid arteries.

Results

The prevalence of minimal, moderate and severe plaque was 35.0%, 8.9% and 1.1%, respectively, and the mean CCA-IMT was 0.73 (SD 0.14) mm. Age, sex, smoking and type 2 diabetes mellitus (T2DM) were the strongest risk factors associated with plaque, followed by systolic blood pressure, total cholesterol, body mass index and family history of myocardial infarct. Low educational level was also strongly and independently associated with plaque. CCA-IMT shared the same risk factors except for a non-significant association with T2DM and family history of myocardial infarction (MI). Participants with T2DM had greater plaque prevalence, 2-fold higher in those <50 years and 17–30% greater in age groups 50–54 to 60–64, and more significant plaques (moderate or severe) were the difference in prevalence was 24% in age group 50–54 and ≥60% in older age groups, compared with non-T2DM.

Conclusions

Carotid plaque and CCA-IMT have mostly common determinants. However, T2DM and family history of MI were associated with plaque but not with CCA-IMT. Greater prevalence and more severe plaques in individuals with T2DM raise the concern that with increasing prevalence of T2DM we may expect an increase in atherosclerosis and its consequences.

To assess the association between perinatal losses and mother's long-term mortality and modification by surviving children and attained education.

Design

A population-based cohort study.

Setting

Norwegian national registries.

Participants

We followed 652 320 mothers with a first delivery from 1967 and completed reproduction before 2003, until 2010 or death. We excluded mothers with plural pregnancies, without information on education (0.3%) and women born outside Norway.

Main outcome measures

Main outcome measures were age-specific (40–69 years) cardiovascular and non-cardiovascular mortality. We calculated mortality in mothers with perinatal losses, compared with mothers without, and in mothers with one loss by number of surviving children in strata of mothers’ attained education (<11 years (low), ≥11 years (high)).

Results

Mothers with perinatal losses had increased crude mortality compared with mothers without; total: HR 1.3 (95% CI 1.3 to 1.4), cardiovascular: HR 1.8 (1.5 to 2.1), non-cardiovascular: HR 1.3 (1.2 to 1.4). Childless mothers with one perinatal loss had increased mortality compared with mothers with one child and no loss; cardiovascular: low education HR 2.7 (1.7 to 4.3), high education HR 0.91 (0.13 to 6.5); non-cardiovascular: low education HR 1.6 (1.3 to 2.2), high education HR 1.8 (1.1 to 2.9). Mothers with one perinatal loss, surviving children and high education had no increased mortality, whereas corresponding mothers with low education had increased mortality; cardiovascular: two surviving children HR 1.7 (1.2 to 2.4), three or more surviving children HR 1.6 (1.1 to 2.4); non-cardiovascular: one surviving child HR 1.2 (1.0 to 1.5), two surviving children HR 1.2 (1.1 to 1.4).

Conclusions

Irrespective of education, we find excess mortality in childless mothers with a perinatal loss. Increased mortality in mothers with one perinatal loss and surviving children was limited to mothers with low education.

To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this.

Design

Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south.

Settings

A wide range of settings within primary and secondary care (these were not restricted in the search).

Results

108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies.

Conclusions

The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.

A total of 139 patients with STEMI randomised to treatment with pPCI or RIC+pPCI.

Interventions

RIC was performed prior to pPCI as four cycles of 5 min upper arm ischaemia and reperfusion with a blood pressure cuff.

Primary outcome measure

Myocardial salvage index (MSI) assessed by single-photon emission computerised tomography. We evaluated the efficacy of RIC in subgroups of patients with or without preinfarction angina or CCBF.

Results

Of 139 patients included in the study, 109 had available data for preinfarction angina status and 54 had preinfarction angina. Among 83 patients with Thrombolysis In Myocardial Infarction flow 0/1 on arrival, 43 had CCBF. Overall, RIC+pPCI increased median MSI compared with pPCI alone (0.75 vs 0.56, p=0.045). Mean MSI did not differ between patients with and without preinfarction angina in either the pPCI alone (0.58 and 0.57; 95% CI –0.17 to 0.19, p=0.94) or the RIC+pPCI group (0.66 and 0.69; 95% CI –0.18 to 0.10, p=0.58). Mean MSI did not differ between patients with and without CCBF in the pPCI alone group (0.51 and 0.55; 95% CI –0.20 to 0.13, p=0.64), but was increased in patients with CCBF versus without CCBF in the RIC+pPCI group (0.75 vs 0.58; 95% CI 0.03 to 0.31, p=0.02; effect modification from CCBF on the effect of RIC on MSI, p=0.06).

Conclusions

Preinfarction angina did not modify the efficacy of RIC in patients with STEMI undergoing pPCI. CCBF to the infarct-related artery seems to be of importance for the cardioprotective efficacy of RIC.

Previous studies have shown that a majority of patients cite altruistic motives, such as contributing to generalisable medical knowledge, as factors motivating clinical trial participation. We sought to examine the impact of making trial results publicly available on patients' willingness to participate in clinical research.

Design

Cross-sectional analysis using a questionnaire developed by a panel with expertise in publication bias, informed consent and survey design.

Setting

A single urban, academic emergency department (ED) in the Northeastern USA.

Participants

799 ED patients.

Outcome Measures

We assessed (1) participants' attitudes towards clinical trial participation, and (2) the impact of whether study results would eventually be made publicly available or not on willingness to participate in a trial.

Results

Of 799 patients surveyed, 36% (95% CI 32% to 39%) reported that they would generally like to participate in a trial, and another 50% (95% CI 47% to 54%) reported that they would consider participation depending on study details. For the majority of participants, the publication of trial results was either important (36%; 95% CI 33% to 40%) or very important (48%; 95% CI 44% to 51%). Most (63%; 95% CI 59% to 66%) reported they would be less likely to participate in a trial if investigators had not publicly released results from a prior study. Additionally, 85% (95% CI 82% to 87%) felt that it was important or very important to receive information about the publication track record of sponsors and investigators during the informed consent process.

Conclusions

The majority of patients in this sample would consider participation in a clinical trial. Patients value the public release of trial results, and believe that the informed consent process should address the possibility of non-publication.

In the summer of 2015, the exodus of Syrian war refugees and saturation of refugee camps in neighbouring countries led to the influx of asylum-seekers in European countries, including Belgium. This study aims to describe the demographic and clinical characteristics of asylum seekers who arrived in a huddled refugee camp, in the centre of a well-developed country with all medical facilities.

Methods

Using a descriptive cross-sectional study design, physicians of Médecins du Monde prospectively registered age, gender, origin, medical symptoms and diagnoses of all patients presenting to an erected field hospital in Brussels in September 2015. Diagnoses were post hoc categorised according to the International Classification of Diseases.

Results

Of 4037 patients examined in the field hospital, 3907 were included and analysed for this study. Over 11% of patients suffered from injuries, but these were outnumbered by the proportion of patients with respiratory (36%), dental (9%), skin (9%) and digestive (8%) diagnoses. More than 49% had features of infections at the time of the consultation.

Conclusions

Asylum seekers arriving in a refugee camp in Brussels after a long and hazardous journey suffer mostly from respiratory, dental, skin and digestive diseases. Still, one in seven suffers from injury. These findings, consistent with other reports, should be anticipated when composing emergency medical teams and interagency emergency health or similar kits to be used in a field hospital, even in a Western European country.

Large middle cerebral artery stroke (space-occupying middle-cerebral-artery (MCA) infarction (SO-MCAi)) results in a very high incidence of death and severe disability. Decompressive hemicraniectomy (DHC) for SO-MCAi results in large reductions in mortality; the level of function in the survivors, and implications, remain controversial. To address the controversy, we pooled available randomised controlled trials (RCTs) that examined the impact of DHC on survival and functional ability in patients with large SO-MCAi and cerebral oedema.

Methods

We searched MEDLINE, EMBASE and Cochrane library databases for randomised controlled trials (RCTs) enrolling patients suffering SO-MCAi comparing conservative management to DHC administered within 96 hours after stroke symptom onset. Outcomes were death and disability measured by the modified Rankin Scale (mRS). We used a random effects meta-analytical approach with subgroup analyses (time to treatment and age). We applied GRADE methods to rate quality/confidence/certainty of evidence.

Results

7 RCTs were eligible (n=338 patients). We found DHC reduced death (69–30% in medical vs surgical groups, 39% fewer), and increased the number of patients with mRS of 2–3 (slight to moderate disability: 14–27%, increase of 13%), those with mRS 4 (severe disability: 10–32%, increase of 22%) and those with mRS 5 (very severe disability 7–11%: increase of 4%) (all differences p<0.0001). We judged quality/confidence/certainty of evidence high for death, low for functional outcome mRS 0–3, and moderate for mRS 0–4 (wide CIs and problems in concealment, blinding of outcome assessors and stopping early).

Conclusions

DHC in SO-MCAi results in large reductions in mortality. Most of those who would otherwise have died are left with severe or very severe disability: for example, inability to walk and a requirement for help with bodily needs, though uncertainty about the proportion with very severe, severe and moderate disability remains (low to moderate quality/confidence/certainty evidence).

Phase IV trials are often used to investigate drug safety after approval. However, little is known about the characteristics of contemporary phase IV clinical trials and whether these studies are of sufficient quality to advance medical knowledge in pharmacovigilance. We aimed to determine the fundamental characteristics of phase IV clinical trials that evaluated drug safety using the ClinicalTrials.gov registry data.

Methods

A data set of 19 359 phase IV clinical studies registered in ClinicalTrials.gov was downloaded. The characteristics of the phase IV trials focusing on safety only were compared with those evaluating both safety and efficacy. We also compared the characteristics of the phase IV trials in three major therapeutic areas (cardiovascular diseases, mental health and oncology). Multivariable logistic regression was used to evaluate factors associated with the use of blinding and randomisation.

Results

A total of 4772 phase IV trials were identified, including 330 focusing on drug safety alone and 4392 evaluating both safety and efficacy. Most of the phase IV trials evaluating drug safety (75.9%) had enrolment <300 with 96.5% <3000. Among these trials, 8.2% were terminated or withdrawn. Factors associated with the use of blinding and randomisation included the intervention model, clinical specialty and lead sponsor.

Conclusions

Phase IV trials evaluating drug safety in the ClinicalTrials.gov registry were dominated by small trials that might not have sufficient power to detect less common adverse events. An adequate sample size should be emphasised for phase IV trials with safety surveillance as main task.

To compare cardiovascular fitness and physical activity of schoolchildren 18 months after London 2012 according to Olympic ‘inspiration’.

Design

A cross-sectional comparison between groups of schoolchildren categorised according to self-reported Olympic inspiration and a repeated cross-sectional comparison using data collected pre-2012.

Setting

Schools within a 50 km radius of the Olympic Park, Stratford, London.

Participants

931 students (10.0–15.9-year-olds) attending 6 schools assessed in 2013 and 2014 (18 (range: 14–20) months after London 2012) and 733 students from the same schools assessed in 2008–2009 (42 (range: 38–46) months before London 2012).

53% of children reported being inspired to try new sports or activities. Compared with those not inspired by the Games, was higher in boys (d=0.43) and girls (d=0.27), who continued to participate in activities at 18(14–20) months. This 45% of sample was also more physically active (boys, d=0.23; girls, d=0.38) than those not or only briefly inspired to participate in activities (boys, d=0.24; girls, d=0.21). Compared with pre-2012 values, was lower post-2012 in boys (d=0.37) and in girls (d=0.38).

Conclusions

High levels of inspiration to participate in new activities reported following London 2012 and positive associations with fitness are encouraging. We cannot discount the possibility that inspired participants may have already been fitter and more active pre-2012. These associations must be interpreted in the context of the significant declines in fitness shown by our repeated cross-sectional comparison. Olympic host countries should employ longitudinal monitoring using objectively measured fitness and physical activity to provide evidence of health-related legacy.

Famine exposure in utero can ‘programme’ an individual towards type 2 diabetes and obesity in later life. We sought to identify, (1) whether Bangladeshis exposed to famine during developmental life are programmed towards diabetes and obesity, (2) whether this programming was specific to gestational or postnatal exposure windows and (3) whether epigenetic differences were associated with famine exposure.

Design

A historical cohort study was performed as part of a wider cross-sectional survey. Exposure to famine was defined through birth date and historical records and participants were selected according to: (A) exposure to famine in postnatal life, (B) exposure to famine during gestation and (C) unexposed.

Setting

Matlab, a rural area in the Chittagong division of Bangladesh.

Participants

Young adult men and women (n=190) recruited to a historical cohort study with a randomised subsample included in an epigenetic study (n=143).

More young adults exposed to famine in gestation were underweight than those postnatally exposed or unexposed. In contrast, more young adults exposed to famine postnatally were overweight compared to those gestationally exposed or unexposed. Underweight adults exposed to famine in gestation in utero were hyperglycaemic following a glucose tolerance test, and those exposed postnatally had elevated fasting glucose, compared to those unexposed. Significant differences in DNA methylation at seven metastable epialleles (VTRNA2-1, PAX8, PRDM-9, near ZFP57, near BOLA, EXD3) known to vary with gestational famine exposure were identified.

435 adult primary care patients with a migration background with unipolar depressive disorder or non-specific chronic low back pain were randomised. Patients who were unable to read in the language of their respective migration background were excluded. Sufficient data were obtained from 203 women and 106 men. The largest group was of Russian origin (202 patients), followed by those of Turkish (52), Polish (30) and Italian (25) origin.

Primary outcome: patient-rated usefulness (USE) assessed immediately after patients received the material. Secondary outcomes: patient-rated usefulness after 8 weeks and 6 months, symptoms of depression (PHQ-9), back pain (Back Pain Core Set) and quality of life (WHO-5) assessed at all time points.

Results

Usefulness was found to be significantly higher (t=1.708, one-sided p=0.04) in the intervention group (USE-score=65.08, SE=1.43), compared with the control group (61.43, SE=1.63), immediately after patients received the material, in the intention-to-treat analysis, with a mean difference of 3.65 (one-sided 95% lower confidence limit=0.13). No significant differences were found for usefulness at follow-up (p=0.16, p=0.71). No significant effect was found for symptom severity in depression (p=0.95, p=0.66, p=0.58), back pain (p=0.40, p=0.45, p=0.32) or quality of life (p=0.76, p=0.86, p=0.21), either immediately after receiving the material, or at follow-up (8 weeks; 6 months). Patients with a lower level of dominant society immersion benefited substantially and significantly more from the intervention than patients with a high level of immersion (p=0.005).

Conclusion

Cultural adaptation of patient information material provides benefits over high quality translations. Clinicians are encouraged to use culture-sensitive material in their consultations, particularly with low-acculturated patients.

To assess why articles are retracted from BioMed Central journals, whether retraction notices adhered to the Committee on Publication Ethics (COPE) guidelines, and are becoming more frequent as a proportion of published articles.

Design/setting

Retrospective cross-sectional analysis of 134 retractions from January 2000 to December 2015.

Results

134 retraction notices were published during this timeframe. Although they account for 0.07% of all articles published (190 514 excluding supplements, corrections, retractions and commissioned content), the rate of retraction is rising. COPE guidelines on retraction were adhered to in that an explicit reason for each retraction was given. However, some notices did not document who retracted the article (eight articles, 6%) and others were unclear whether the underlying cause was honest error or misconduct (15 articles, 11%). The largest proportion of notices was issued by the authors (47 articles, 35%). The majority of retractions were due to some form of misconduct (102 articles, 76%), that is, compromised peer review (44 articles, 33%), plagiarism (22 articles, 16%) and data falsification/fabrication (10 articles, 7%). Honest error accounted for 17 retractions (13%) of which 10 articles (7%) were published in error. The median number of days from publication to retraction was 337.5 days.

Conclusions

The most common reason to retract was compromised peer review. However, the majority of these cases date to March 2015 and appear to be the result of a systematic attempt to manipulate peer review across several publishers. Retractions due to plagiarism account for the second largest category and may be reduced by screening manuscripts before publication although this is not guaranteed. Retractions due to problems with the data may be reduced by appropriate data sharing and deposition before publication. Adopting a checklist (linked to COPE guidelines) and templates for various classes of retraction notices would increase transparency of retraction notices in future.

Of 751 girls enrolled 644 were followed-up for a median of 10.9 months. Cups or pads did not reduce school dropout risk (control=8.0%, cups=11.2%, pads=10.2%). Self-reported absence was rarely reported and not assessable. Prevalence of STIs in the end-of-study survey among controls was 7.7% versus 4.2% in the cups arm (adjusted prevalence ratio (aPR) 0.48, 0.24 to 0.96, p=0.039), 4.5% with pads (aPR=0.62; 0.37 to 1.03, p=0.063), and 4.3% with cups and pads pooled (aPR=0.54, 0.34 to 0.87, p=0.012). RTI prevalence was 21.5%, 28.5% and 26.9% among cup, pad and control arms, 71% of which were bacterial vaginosis, with a prevalence of 14.6%, 19.8% and 20.5%, per arm, respectively. Bacterial vaginosis was less prevalent in the cups (12.9%) compared with pads (20.3%, aPR=0.65, 0.44 to 0.97, p=0.034) and control (19.2%, aPR=0.67, 0.43 to 1.04, p=0.075) arm girls enrolled for 9 months or longer. No adverse events were identified.

Conclusions

Provision of menstrual cups and sanitary pads for ~1 school-year was associated with a lower STI risk, and cups with a lower bacterial vaginosis risk, but there was no association with school dropout. A large-scale trial on menstrual cups is warranted.

To explore the prevalence of, and associated factors contributing to burnout among senior doctors and dentists working in the New Zealand's public health system.

Design

Cross-sectional, mixed methods study.

Setting

New Zealand's 20 district health boards (DHBs).

Participants

A total of 1487 of 3740 senior doctors and dentists who are members of the Association of Salaried Medical Specialists working in DHBs were recruited (response rate 40%).

Primary and secondary outcome measures

Gender, age, self-rated health status, vocation and hours of work per week were obtained from an electronic questionnaire. Burnout was measured using the Copenhagen Burnout Inventory. Qualitative data taken from an open-ended comments section was coded using grounded theory and used for contextual data.

Results

The overall prevalence of high personal burnout was 50%. Women aged <40 years had 71% prevalence of high personal burnout. Prevalence of high work-related burnout and patient-related burnout was 42% and 16%, respectively. Those working in emergency medicine and psychiatry had significantly higher mean work-related burnout than other specialties (p<0.001). On multivariate analysis, having fair or poor health status (OR 10.8, 95% CI 6.8 to 17.1), working more than 14 consecutive hours (OR 1.43, 95% CI 1.12 to 1.82) and being a woman (OR 2.14, 95% CI 1.68 to 2.73) were independently associated with high personal and work-related burnout. Personal burnout rates decreased with age (age 30–39 OR 2.86, 95% CI 1.78 to 4.59, age 40–49 OR 2.45, 95% CI 1.70 to 3.55, age 50–59 OR 1.70, 95% CI 1.17 to 2.46, compared with age>60). Qualitative data emphasised intense and unrelenting workloads, under-staffing, onerous on-call duties and frustrations with management as factors contributing to burnout.

Conclusions

High burnout appears prevalent in New Zealand's senior doctors and dentists. Many attribute their feelings of burnout to work conditions. These findings may assist with understanding contributors to burnout and with developing strategies to ameliorate the high burnout found across this cohort.

The aim of the study was to compare therapy persistence among patients who started with one of three drug regimens: a monotherapy, or combination therapy either as a fixed combination (ie, ‘single pill’) or as a free combination (ie, two separate antihypertensive agents).

Design

In a secondary data analysis, we used descriptive statistics and multivariate logistic regression to measure the effect of the three therapy regimens on therapy persistence over 4 years.

Setting

Prescription data from a large German statutory health insurance provider.

Participants

All patients who started with a new antihypertensive therapy in 2007 or 2008 (n=8032) were included and followed for 4 years.

Primary outcome measure

Therapy persistence, defined as receiving a refill prescription no later than within 180 days.

Results

The persistence rates after 4 years were nearly identical among patients who started with a monotherapy (40.3%) or a fixed combination of two drugs (39.8%). However, significantly more patients who started with free-drug combinations remained therapy persistent (56.4%), resulting in an OR of 2.00 (95% CI 1.6 to 2.5; p<0.0001) for free combinations versus fixed combinations. This trend was observed in all age groups and for men and women. At the end of the study period, the number of different antihypertensive agents was still similar between patients who started with a fixed combination (2.41) and patients who started with a free combination (2.28).

Conclusions

While single-pill combinations make it easier to take different drugs at once, the risk is high that these several substances are stopped at once. Therapy persistence was significantly better for patients who started with a free-drug combination without taking much fewer different antihypertensive drugs as those with a fixed combination.

To explore the nature of paternal involvement in early child-rearing adopting a social developmental perspective, and estimate its effect on behavioural outcomes of children aged 9 and 11 years.

Setting

The data come from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort recruited in the former county of Avon in the southwest of England.

Participants

Out of the 14 701 children in this cohort who were alive at 1 year, 10 440 children were living with both parents at 8 months and were therefore eligible. Outcome data were available for 6898 children at 9 years and 6328 children at 11 years.

Main exposure

Paternal involvement was measured using factor scores obtained through factor analysis of fathers’ responses on their participation in, understanding of, and feelings about their child's early upbringing.

Outcome

Behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ) total difficulties score.

Results

3 factors were identified in the factor analysis: Factor 1 described fathers’ emotional response to the child; factor 2 measured the frequency of fathers’ involvement in domestic and childcare activities; factor 3 characterised fathers’ feelings of security in their role as parent and partner. Children of fathers with high scores on factors 1 and 3 had 14% (OR 0.86, 95% CI 0.79 to 0.94, p=0.001) and 13% (OR 0.87, 95% CI 0.79 to 0.96, p=0.006), respectively, lower adjusted odds of behavioural problems at 9 years. Factors 1 and 3 were associated with comparable reduction in adjusted odds of behavioural problems at 11 years (OR 0.89, 95% CI 0.81 to 0.98, p=0.017 and OR 0.89, 95% CI 0.81 to 0.99, p=0.034, respectively). Factor 2 was not associated with the outcome.

Conclusions

Psychological and emotional aspects of paternal involvement in children's early upbringing, particularly how new fathers see themselves as parents and adjust to the role, rather than the quantity of direct involvement in childcare, is associated with positive behavioural outcomes in children.

Nationwide drug usage study using data of patients with ACS discharged from hospitals in Finland.

Participants

The study population consisted of 54 416 patients (aged ≥18 years) following hospital admission for unstable angina pectoris or myocardial infarction during 2009–2013. Patients were classified as either OAP or non-OAP users based on drug purchases within 7 days of discharge.

Outcome measures

Initiation of and a 12-month persistence with OAP medication.

Results

In total, 49% of patients with ACS received OAP treatment after hospital discharge. Women represented 40% of the population, but only 32% of them became OAP users (adjusted OR for initiation compared with men 0.8; p<0.001). Patients not treated with percutaneous coronary intervention (PCI), elderly and patients with dementia/Alzheimer's disease, atrial fibrillation or warfarin treatment were less likely to be treated with OAP. If initiated, they were less likely to complete the recommended 12 months’ medication (adjusted risk increment >38% and p<0.001 for all). The OAP users showed good compliance with immediate initiation (92% within 1 day of discharge) and high mean medication possession rate (99%). Among OAP users, the usage of other secondary prevention drugs after ACS was more common than in non-OAP-treated patients (difference >20 percentage points for each).

Conclusions

Only half of the patients with ACS received guideline-recommended ADP receptor-inhibiting OAP treatment after hospital discharge, suggesting suboptimal treatment practices. Non-PCI-treated patients and patients with increased age, unstable angina, dementia or atrial fibrillation appear to have the highest risk of deficient treatment with OAPs. OAP users, however, showed good compliance during drug usage.

Socioeconomic differences in screening have been well documented in upper-income countries; however, few studies have examined socioeconomic status (SES) over the life-course in relation to cancer screening in lower-income and middle-income countries. Here, we examine individual, parental and life-course SES differences in breast and cervical cancer screening among women in India, China, Mexico, Russia and South Africa.

Setting

Data from the WHO's Study on Global Ageing and Adult Health (SAGE) 2007–2008 data were used for survey-weighted multivariable regression analysis. We examined the association between individual, parental and life-course SES in relation to breast and cervical cancer screening using education-based and employment-based measures of SES.

42.4% of children had 2 or more adverse health conditions (co-occurrence). Co-occurrence was more common in boys and children from lower income households. Latent class analysis identified 6 classes: ‘normative’ (57.4%): ‘atopic burdened’ (14.0%); ‘socioemotional burdened’ (11.0%); ‘unfavourable weight/injury’ (7.7%); ‘eczema/injury’ (6.0%) and ‘eczema/unfavourable weight’ (3.9%). As with co-occurrence, class membership differed by sociodemographic factors: boys, children of mothers with lower educational attainment and children from lower income households were more likely to be in the ‘socioemotional burdened’ class. Children of mothers with higher educational attainment were more likely to be in the ‘normative’ and ‘eczema/unfavourable weight’ classes.

Conclusions

Co-occurrence of adverse health conditions at age 11 is common and is associated with adverse socioeconomic circumstances. Holistic, child focused care, particularly in boys and those in lower income groups, may help to prevent and reduce co-occurrence in later childhood and adolescence.

To determine the clinical effectiveness of ultrasound tailored treatment in patients with acute subacromial disorders.

Design

Pragmatic randomised controlled trial.

Setting

Dutch general practice.

Participants

Patients aged 18–65 years with acute (duration <3 months) unilateral shoulder pain and no previous treatment, in whom the general practitioner suspected a subacromial disorder was enrolled.

Interventions

All patients underwent ultrasound imaging of the affected shoulder. Patients who were still symptomatic after a qualification period of 2 weeks with standard treatment were randomised to treatment tailored to ultrasound diagnosis (disclosure of the ultrasound diagnosis) or usual care (non-disclosure of the ultrasound diagnosis).

129 patients were included. 18 patients recovered during the 2-week qualification period, resulting in 111 randomised patients; 56 were allocated to ultrasound tailored treatment and 55 to usual care. After 1 year, no statistically significant differences in recovery were found between the ultrasound tailored treatment group (72.5% (37/51)) and the usual care group (60% (30/50), OR 2.24 (95% CI 0.72 to 6.89; p=0.16)). Also, healthcare use was similar.

Conclusions

This study has shown no clinically significant difference in the primary outcome measure between the ultrasound tailored treatment and usual care groups. Furthermore, there was no overall difference in healthcare resources used between groups. Although no formal cost data are included, one can only assume that the ultrasound examinations are additional costs for the intervention group, which cannot be justified in routine practice based on this trial. Based on this study, no change in current pragmatic guidelines to incorporate early ultrasound imaging can be recommended.

To describe the impact of Street Triage (ST) on the number and rate of Section 136 Mental Health Act (S136) detentions in one NHS Mental Health and Disability Trust (Northumberland, Tyne and Wear (NTW)).

Design

Comparative descriptive study of numbers and rates of S136 detentions prior to and following the introduction of ST in NTW. More detailed data were obtained from one local authority in the NTW area.

Introduction of a ST service in NTW. The main outcome measures were routinely collected data on the number and rate of ST interventions as well as patterns of the numbers and rates of S136 detentions. These were collected retrospectively.

Results

The annual rate of S136 detentions reduced by 56% in the first year of ST (from 59.8 per 100 000 population to 26.4 per 100 000). There was a linear relationship between the rate of ST in each locality and the reduction in rate of S136 detentions. There were 1623 ST contacts in the first 3 localities to have a ST service during its first year; there were also 403 fewer S136 detentions. Data from Sunderland indicate a 78% reduction in S136 use and a significant reduction in the number and proportion of adult admissions that originated from S136 detentions.

Conclusions

There is evidence to support the hypothesis that ST decreases the rate of s136 detention. When operating across the whole of NTW, ST resulted in 50 fewer S136 detentions a month, which represents a substantial reduction.

Although all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects. Despite the centrality of integrated care to current policy, questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity.

There is a possibility of underestimation in the smoking rate surveyed by self-reported questionnaires. This study investigated the difference between the Korean female smoking rate as determined by self-reports and that determined by a biochemical test and elucidated the relationship between women's smoking and laryngeal disorders.

This study defined smokers as those with urine cotinine contents of 50 ng/mL and over. Confounding factors included age, level of education, household income, occupation and problem drinking in the past year. For statistical tests, OR and 95% CI were presented by using complex samples logistic regression.

Results

While there was no relationship between smoking as determined by a self-reported questionnaire and laryngeal disorders, smoking as determined by the urine cotinine test had a significant relationship with laryngeal disorders (p<0.05). After all the confounding factors were adjusted, those with urine cotinine concentrations of over 50 ng/mL had a 2.1 times higher risk of laryngeal disorders than those with urine cotinine concentrations of <50 ng/mL (OR=2.05, 95% CI 1.11 to 3.78) (p<0.05).

Conclusions

This national cross-sectional study verified that smoking is a significant risk factor for laryngeal disorders. Longitudinal studies are required to identify the causal relationship between smoking and laryngeal disorders.

Information on diabetes status, biomedical/sociodemographic variables, medical history and on healthcare usage and productivity losses was assessed in standardised interviews and examinations. Healthcare usage and productivity losses were costed with reference to unit prices and excess costs of type 2 diabetes were calculated using generalised linear models.

Results

Individuals with type 2 diabetes had 1.81 (95% CI 1.56 to 2.11) times higher direct (3352 vs 1849) and 2.07 (1.51 to 2.84) times higher indirect (4103 vs 1981) annual costs than those without diabetes. Cardiovascular complications, a long diabetes duration and treatment with insulin were significantly associated with increased direct costs; however, glycaemic control was only weakly insignificantly associated with costs.

Conclusions

This study illustrates the substantial direct and indirect societal cost burden of type 2 diabetes in Germany. Strong effort is needed to optimise care to avoid progression of the disease and costly complications.

To investigate the nature of physicians' use of research evidence in experimental conditions of open access to inform training and policy.

Design

This qualitative study was a component of a larger mixed-methods initiative that provided 336 physicians with relatively complete access to research literature via PubMed and UpToDate, for 1 year via an online portal, with their usage recorded in web logs. Using a semistructured interview protocol, a subset of 38 physician participants were interviewed about their use of research articles in general and were probed about their reasons for accessing specific articles as identified through their web logs. Transcripts were analysed using a general inductive approach.

Setting

Physician participants were recruited from and registered in the USA.

Participants

38 physicians from 16 US states, engaged in 22 medical specialties, possessing more than 1 year of experience postresidency training participated.

Results

26 participants attested to the value of consulting research literature within the context of the study by making reference to their roles as clinicians, educators, researchers, learners, administrators and advocates. The physicians reported previously encountering what they experienced as a prohibitive paywall barrier to the research literature and other frustrations with the nature of information systems, such as the need for passwords.

Conclusions

The findings, against the backdrop of growing open access to biomedical research, indicate that a minority of physicians, at least initially, is likely to seek out and use research and do so in a variety of common roles. Physicians' use of research in these roles has not traditionally been part of their training or part of the considerations for open access policies. The findings have implications for educational and policy initiatives directed towards increasing the effectiveness of this access to and use of research in improving the quality of healthcare.

The prevalence of maternal obesity at the beginning of pregnancy is increasing. However, there are some studies reporting the stabilisation of obesity epidemic or even the downward trend in the general population.

Objective

To determine the prevalence of overweight and obesity in Lithuanian pre-pregnant women during 3 decades.

Methods

This observational retrospective study included a sample of 2827, women aged 18–44 years who gave birth in 1987–1989, 1996–1997 and 2007–2010: 861 (30.5%), 995 (35.2%) and 971 (34.3%), respectively. All women were divided into groups by body mass index (BMI) calculated from self-reported weight and height, and age reported during the first antenatal visit. Quantitative parametric variables were expressed as mean and SD; qualitative variables, as absolute numbers (n) and percentage (%). For parametric data, analysis of variance (ANOVA) was used. Differences were considered statistically significant at p<0.05.

Results

The prevalence of overweight and obesity among women aged 18–24 years decreased from 20.9% in 1987–1989 to 9.5% in 1996–1997 but increased to 15.7% in 2007–2010; among women aged 25–34 years, decreased from 35.5% in 1987–1989 to 23% in 1996–1997 and to 22.4% in 2007–2010; and among women aged 35–44 years decreased from 64.9% in 1987–1989 to 34% in 1996–1997 but increased to 45.3% in 2007–2010. BMI increased with an increasing age (r=0.254, p<0.05). Analysis by separate periods (1987–1989, 1996–1997 and 2007–2010) revealed a positive correlation between BMI and age at the first antenatal visit in all periods (r=0.325, p<0.01; r=0.266, p<0.01; and r=0.210, p<0.01, respectively).

Conclusions

The prevalence of overweight and obesity among pre-pregnant women tended to decrease in the Lithuanian urban area during 3 decades. A slight increase in overweight and obesity documented in 2007–2010 compared with 1996–1997 most likely was caused by older maternal age.

To identify general practitioner (GP) views and understanding on the use of delayed prescribing in primary care.

Design

Qualitative semistructured telephone interview study.

Setting

Primary care general practices in England.

Participants

32 GPs from identified high-prescribing and low-prescribing general practices in England.

Method

Semistructured telephone interviews were conducted with GPs identified from practices within clinical commissioning groups with the highest and lowest prescribing rates in England. A thematic analysis of the data was conducted to generate themes.

Results

All GPs had a good understanding of respiratory tract infection (RTI) management and how the delayed prescribing approach could be used in primary care. However, GPs highlighted factors that were influential as to whether delayed prescribing was successfully carried out during the consultation. These included the increase in evidence of antimicrobial resistance, and GPs' prior experiences of using delayed prescribing during the consultation. The patient–practitioner relationship could also influence treatment outcomes for RTI, and a lack of an agreed prescribing strategy within and between practices was considered to be of significance to GPs. Participants expressed that a lack of feedback on prescribing data at an individual and practice level made it difficult to know if delayed prescribing strategies were successful in reducing unnecessary consumption. GPs agreed that coherent and uniform training and guidelines would be of some benefit to ensure consistent prescribing throughout the UK.

Conclusions

Delayed prescribing is encouraged in primary care, but is not always implemented successfully. Greater uniformity within and between practices in the UK is needed to operationalise delayed prescribing, as well as providing feedback on the uptake of antibiotics. Finally, GPs may need further guidance on how to answer the concerns of patients without interpreting these questions as a demand for antibiotics, as well as educating the patient about antimicrobial resistance and supporting a good patient–practitioner relationship.

To identify determinants of the initial employment of physician assistants (PAs) for inpatient care as well as of the sustainability of their employment.

Design

We conducted a qualitative study with semistructured interviews with care providers. Interviews continued until data saturation was achieved. All interviews were transcribed verbatim. A framework approach was used for data analysis. Codes were sorted by the themes, bringing similar concepts together.

Setting

This study was conducted between June 2014 and May 2015 within 11 different hospital wards in the Netherlands. The wards varied in medical speciality, as well as in hospital type and the organisational model for inpatient care.

Participants

Participant included staff physicians, residents, PAs and nurses.

Results

The following themes emerged to be important for the initial employment of PAs and the sustainability of their employment: the innovation, individual factors, professional interactions, incentives and resources, capacity for organisational change and social, political and legal factors.

Conclusions

10 years after the introduction of PAs, there was little discussion among the adopters about the added value of PAs, but organisational and financial uncertainties played an important role in the decision to employ and continue employment of PAs. Barriers to employ and continue PA employment were mostly a consequence of locally arranged restrictions by hospital management and staff physicians, as barriers regarding national laws, PA education and competencies seemed absent.

Studies in patients seeking medically assisted reproduction have shown that smoking reduces fertility, but little information is available in the general population. We assessed the associations between smoking and the number of children, childbearing planning and age at menopause in a representative sample of the population of Lausanne, Switzerland.

Methods

Data from 6711 participants (3530 women, age range 35–75 years) collected between 2003 and 2006 and again in 2009 and 2012. Smoking status, number of offsprings and age of menopause were assessed.

Results

Women who currently smoke had significantly less children than former or never smokers: the number of children per women (average±SD) was 1.38±1.05, 1.45±1.07 and 1.576±1.16, respectively (p<0.001). Women who currently smoke had their first child at an earlier age than the others: 26.7±5.2, 27.4±5.4 and 26.9±5.2 years old for current, former and never smokers, respectively, (p=0.01). Similar findings were found for men: number of children per men 1.475±1.16, 1.67±1.13 and 1.55±1.22 for current, former and never smokers, respectively (p<0.001); no difference was found regarding age at the first child. The difference persisted after multivariate adjustment (adjusted for age, body mass index, Caucasian origins, alcohol consumption, caffeinated drinks consumption, educational level, receiving social help and women taking contraceptives) for the age at first child among women. No association was found between Heaviness of Smoking Index and the number of children among current smokers in both genders. Women who smoke had their menopause more than 1 year prior than never-smoking women (48.9±0.2 years compared with 47.8±0.3 years, respectively, p=0.002).

Conclusions

Smoking is associated with an earlier age of having the first child and of menopause among women.

Men who have sex with men (MSM) in sub-Saharan Africa remain hidden and hard to reach for involvement in HIV and sexually transmitted infection (STI) services. The aim of the current study was to describe MSM social networks in a large and a small Tanzanian city in order to explore their utility for peer-based healthcare interventions.

Methods

Data were collected through respondent-driven sampling (RDS) in Dar es Salaam (n=197) and in Tanga (n=99) in 2012 and 2013, using 5 and 4 seeds, respectively. All results were adjusted for RDS sampling design.

Results

Mean personal network size based on the number of MSM who were reported by the participants, as known to them was 12.0±15.5 in Dar es Salaam and 7.6±8.1 in Tanga. Mean actual RDS network size was 39.4±31.4 in Dar es Salaam and 25.3±9.7 in Tanga. A majority (97%) reported that the person from whom they received the recruitment coupon was a sexual partner, close friend or acquaintance. Homophile in recruitment patterns (selective affiliation) was present for age, gay openness, and HIV status in Dar es Salaam, and for sexual identification in Tanga.

Conclusions

The personal network sizes and existence of contacts between recruiter and referral indicate that it is possible to use peer-driven interventions to reach MSM for HIV/STI interventions in larger and smaller sub-Saharan African cities. The study was reviewed and approved by the University of Texas Health Science Center's Institutional Review Board (HSC-SPH-10-0033) and the Tanzanian National Institute for Medical Research (NIMR/HQ/R.8a/Vol. IX/1088).

Postnatal maternal mental health problems, including depression and anxiety, entail a significant burden globally, and finding cost-effective preventive solutions is a public policy priority. This paper presents a cost-effectiveness analysis of the intervention, What Were We Thinking (WWWT), for the prevention of postnatal maternal mental health problems.

Design

The economic evaluation, including cost-effectiveness and cost-utility analyses, was conducted alongside a cluster-randomised trial.

Setting

48 Maternal and Child Health Centres in Victoria, Australia.

Participants

Participants were English-speaking first-time mothers attending participating Maternal and Child Health Centres. Full data were collected for 175 participants in the control arm and 184 in the intervention arm.

Intervention

WWWT is a psychoeducational intervention targeted at the partner relationship, management of infant behaviour and parental fatigue.

Outcome measures

The evaluation considered public sector plus participant out-of-pocket costs, while outcomes were expressed in the 30-day prevalence of depression, anxiety and adjustment disorders, and quality-adjusted life years (QALYs). Incremental costs and outcomes were estimated using regression analyses to account for relevant sociodemographic, prognostic and clinical characteristics.

Results

The intervention was estimated to cost $A118.16 per participant. The analysis showed no statistically significant difference between the intervention and control groups in costs or outcomes. The incremental cost-effectiveness ratios were $A36 451 per QALY gained and $A152 per percentage-point reduction in 30-day prevalence of depression, anxiety and adjustment disorders. The estimate lies under the unofficial cost-effectiveness threshold of $A55 000 per QALY; however, there was considerable uncertainty surrounding the results, with a 55% probability that WWWT would be considered cost-effective at that threshold.

Conclusions

The results suggest that, although WWWT shows promise as a preventive intervention for postnatal maternal mental health problems, further research is required to reduce the uncertainty over its cost-effectiveness as there were no statistically significant differences in costs or outcomes.

No comprehensive study currently exists on the supply of ophthalmologists across Latin America. We explored sociogeographic inequalities in the availability and distribution of ophthalmologists across 14 Latin American countries.

Methods

The National Ophthalmologic Societies of Argentina, Bolivia, Brazil, Colombia, Costa Rica, Chile, the Dominican Republic, Ecuador, Guatemala, Mexico, Paraguay, Peru, Uruguay and Venezuela provided data on affiliated ophthalmologists by first-order subnational divisions in 2013. Human Development Index (HDI) estimates at the corresponding subnational division were used as equity stratifiers. Distributional inequality of ophthalmologists within each country was assessed by the health concentration index (HCI) and the index of dissimilarity (ID), along with the mean level of ophthalmologists per population.

Results

Across all countries studied, there were 5.2 ophthalmologists per 100 000 population on average (95% CI 5.0 to 5.4) in 2013, with a mean HCI of 0.26 (0.16 to 0.37) and a mean relative ID of 22.7% (20.9% to 24.7%). There was wide inequality in ophthalmologist availability between countries, ranging from 1.2 (1.1 to 1.4) in Ecuador to 8.6 (8.5 to 8.8) in Brazil. All countries had positive (ie, pro-rich) HCI values ranging from 0.68 (0.66 to 0.71) in Guatemala to 0.02 (–0.11 to 0.14) in Venezuela. Correspondingly, redistributive potential to achieve equity was closest in Venezuela (ID: 1.5%) and farthest in Guatemala (ID: 60.3%). Benchmarked against regional averages, most countries had a lower availability of ophthalmologists and higher relative inequality.

Conclusions

There is high inequality in the level and distribution of ophthalmologists between and within countries in Latin America, with a disproportionate number concentrated in more developed, socially advantaged areas. More equitable access to ophthalmologists could be achieved by implementing incentivised human resources redistribution programmes and by improving the social determinants of health in underserved areas.

The majority of cardiovascular diagnoses in the Danish National Patient Registry (DNPR) remain to be validated despite extensive use in epidemiological research. We therefore examined the positive predictive value (PPV) of cardiovascular diagnoses in the DNPR.

Design

Population-based validation study.

Setting

1 university hospital and 2 regional hospitals in the Central Denmark Region, 2010–2012.

Participants

For each cardiovascular diagnosis, up to 100 patients from participating hospitals were randomly sampled during the study period using the DNPR.

Main outcome measure

Using medical record review as the reference standard, we examined the PPV for cardiovascular diagnoses in the DNPR, coded according to the International Classification of Diseases, 10th Revision.

Results

A total of 2153 medical records (97% of the total sample) were available for review. The PPVs ranged from 64% to 100%, with a mean PPV of 88%. The PPVs were ≥90% for first-time myocardial infarction, stent thrombosis, stable angina pectoris, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, takotsubo cardiomyopathy, arterial hypertension, atrial fibrillation or flutter, cardiac arrest, mitral valve regurgitation or stenosis, aortic valve regurgitation or stenosis, pericarditis, hypercholesterolaemia, aortic dissection, aortic aneurysm/dilation and arterial claudication. The PPVs were between 80% and 90% for recurrent myocardial infarction, first-time unstable angina pectoris, pulmonary hypertension, bradycardia, ventricular tachycardia/fibrillation, endocarditis, cardiac tumours, first-time venous thromboembolism and between 70% and 80% for first-time and recurrent admission due to heart failure, first-time dilated cardiomyopathy, restrictive cardiomyopathy and recurrent venous thromboembolism. The PPV for first-time myocarditis was 64%. The PPVs were consistent within age, sex, calendar year and hospital categories.

Conclusions

The validity of cardiovascular diagnoses in the DNPR is overall high and sufficient for use in research since 2010.

Concerns have been raised regarding the quality and completeness of abstract reporting in evidence reviews, but this had not been evaluated in meta-analyses of diagnostic accuracy. Our objective was to evaluate reporting quality and completeness in abstracts of systematic reviews with meta-analyses of depression screening tool accuracy, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for Abstracts tool.

Design

Cross-sectional study.

Inclusion Criteria

We searched MEDLINE and PsycINFO from 1 January 2005 through 13 March 2016 for recent systematic reviews with meta-analyses in any language that compared a depression screening tool to a diagnosis based on clinical or validated diagnostic interview.

Data extraction

Two reviewers independently assessed quality and completeness of abstract reporting using the PRISMA for Abstracts tool with appropriate adaptations made for studies of diagnostic test accuracy. Bivariate associations of number of PRISMA for Abstracts items complied with (1) journal abstract word limit and (2) A Measurement Tool to Assess Systematic Reviews (AMSTAR) scores of meta-analyses were also assessed.

Quality and completeness of reporting were found to be suboptimal. Journal editors should endorse PRISMA for Abstracts and allow for flexibility in abstract word counts to improve quality of abstracts.

The aim was to evaluate a common-sense, behavioural change intervention to implement clinical guidelines for asthma management in the community pharmacy setting.

Design

The components of the common-sense intervention were described in terms of categories and dimensions using the Intervention Taxonomy (ITAX) and Behaviour Change Techniques (BCTs) using the Behaviour Change Wheel (BCW), Capability, Opportunity and Motivation-Behaviour (COM-B) System and Behaviour Change Techniques Taxonomy (BCTTv1). The retrospective application of these existing tools facilitated evaluation of the mechanism, fidelity, logistics and rationale of the common-sense intervention.

Intervention

The initial intervention study was conducted in 336 community pharmacies in the metropolitan area of Perth, Western Australia. Small-group workshops were conducted in 25 pharmacies; 162 received academic detailing and 149 acted as controls. The intervention was designed to improve pharmacy compliance with guidelines for a non-prescription supply of asthma reliever medications.

Results

Retrospective application of ITAX identified mechanisms for the short-acting β agonists intervention including improving knowledge, behavioural skills, problem-solving skills, motivation and self-efficacy. All the logistical elements were considered in the intervention design but the duration and intensity of the intervention was minimal. The intervention was delivered as intended (as a workshop) to 13.4% of participants indicating compromised fidelity and significant adaptation. Retrospective application of the BCW, COM-B system and BCTTv1 identified 9 different behaviour change techniques as the rationale for promoting guideline-based practice change.

Conclusions

There was a sound rationale and clear mechanism for all the components of the intervention but issues related to logistics, adaptability and fidelity might have affected outcomes. Small group workshops could be a useful implementation strategy in community pharmacy, if logistical issues can be overcome and less adaptation occurs. Duration, intensity and reinforcement need consideration for successful wider implementation. Further qualitative evaluations, triangulation of research and evaluations across interventions should be used to provide a greater understanding of unresolved issues.

Catchment area for South London and Maudsley National Health Service Foundation Trust, provider for 1.2 million people in Southeast London.

Participants

Every individual with diagnosis of Alzheimer's disease seen and treated by mental health services in the catchment area, with at least one rating of cognition, not resident in care home at time of assessment (n=3075).

Interventions

Usual treatment.

Main outcome measures

Risk of admission to, and days spent in three settings during 6-month period following routine clinical assessment: care home, mental health inpatient care and general hospital inpatient care.

Most people with dementia prefer to remain in their own homes, and funding bodies see this as cheaper than institutionalisation. Better treatment in the community that reduces health and social care needs of Alzheimer's patients would reduce admission rates. Living alone, poor living circumstances and functional problems all raise admission rates, and so major cuts in social care budgets increase the risk of high-cost admissions which older people do not want. Routinely collected data can be used to reveal local patterns of admission and costs.

We aimed to investigate the associations of physical activity and change in physical activity with incident asthma in a cohort of Norwegian adults.

Design

We conducted a prospective cohort study using data on self-reported physical activity from 3 waves of the Nord-Trøndelag Health Study. Physical activity was reported at the first and second surveys (1985–1986 and 1995–1997). Physical activity was defined from the second survey as inactive or active and the active group was further defined as very low, low, moderate and high. Change in physical activity was defined from the first and second surveys.

Setting

A large population-based health survey in Norway.

Participants

We followed 18 894 adults over 11 years who were free from asthma at baseline in 1995–1997.

Outcome

Incident asthma was reported in the third survey (2006–2008).

Results

The cumulative incidence of asthma was 3.6% over the 11 years. The adjusted OR for incident asthma among active participants compared with inactive participants was 0.95 (95% CI 0.69 to 1.34). The adjusted OR for those who were active in the first or second survey versus those who were inactive in both surveys was 0.64 (95% CI 0.34 to 1.38); however, this association was strongly attenuated in sensitivity analysis (OR 0.93, 95% CI 0.38 to 3.09).

Conclusions

We did not observe statistically significant associations of physical activity or change in physical activity with incident asthma in adults over the 11-year follow-up.

We compared work disability of patients with multiple sclerosis (MS) from 5 years before with 5 years after diagnosis, with that of matched controls, and analysed whether progression in work disability among patients with MS was associated with sociodemography.

Annual net days of sickness absence (SA) and disability pension (DP), used as a proxy for work disability, followed from 5 years before to 5 years after diagnosis (ie, T–5–T+5). For patients with MS, regression was used to identify sociodemographic factors related to progression in work disability.

Results

Work disability of patients with MS increased gradually between T–5 and T–1 (mean: 46–82 days) followed by a sharp increase (T+1, 142 days), after which only a marginal increase was observed (T+5, 149 days). The matched controls had less work disability, slightly increasing during the period to a maximum of ~40 days. Men with MS had a sharper increase in work disability before diagnosis. High educational level was associated with less progression in work disability before and around diagnosis.

Conclusions

Patients with MS had more work disability days also 5 years before diagnosis. Several sociodemographic variables were associated with the absolute level and the progression in SA and DP.

Among infants with a birth GA of 25–30 weeks, birth weight SD score and postnatal weight were lower in those developing ROP and BPD. Infants developing ROP showed lower growth rates during postnatal weeks 7–9 in the 23–24 weeks GA group, during weeks 4–6 in the 25–26 weeks GA group and during weeks 1–5 in the 27–30 weeks GA group. Infants with BPD born at 27–30 weeks GA showed lower growth rates during postnatal weeks 3–5. Infants with NEC had lower growth rates after postnatal week 6 in all GA groups, with no significant differences in birth weight SD score. IVH was not associated with prenatal or postnatal growth.

Conclusions

In this cohort study of extremely preterm infants, we found that the postnatal growth pattern was associated with morbidities such as ROP, BPD and NEC as well as with gestational age at birth.

To gain insights into the process of nurses’ changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care, and into the factors that contributed to these changes in their perceptions.

A 5-month training programme designed to enable nurses to support the self-management of dual sensory impaired older adults in long-term care.

Primary outcomes

Nurses’ perceptions on relevance and feasibility of the self-management programme collected from nurses’ semistructured coaching diaries over the 5-month training and intervention period, as well as from trainers’ reports.

Results

Nurses’ initial negative perceptions on relevance and feasibility of the intervention changed to positive as nurses better understood the concept of autonomy. Through interactions with older adults and by self-evaluations of the effect of their behaviour, nurses discovered that their usual care conflicted with client autonomy. From that moment, nurses felt encouraged to adapt their behaviour to the older adults’ autonomy needs. However, nurses’ initial unfamiliarity with conversation techniques required a longer exploration period than planned. Once client autonomy was understood, nurses recommended expanding the intervention as a generic approach to all their clients, whether dual sensory impaired or not.

Conclusions

Longitudinal data collection enabled exploration of nurses’ changes in perceptions when moving towards self-management support. The training programme stimulated nurses to go beyond ‘protocol thinking’, discovering client autonomy and exploring the need for their own behavioural adaptations. Educational programmes for practical nurses should offer more longitudinal coaching of autonomy supportive conversational skills. Intervention programming should acknowledge that change is a process rather than an event, and should include self-evaluations of professional behaviours over a period of time.

Peer facilitators play an important role in determining the success of many support groups for patients with medical illnesses. However, many facilitators do not receive training for their role and report a number of challenges in fulfilling their responsibilities. The objective of this systematic review was to evaluate the effects of training and support programmes for peer facilitators of support groups for people with medical illnesses on (1) the competency and self-efficacy of group facilitators and (2) self-efficacy for disease management, health outcomes and satisfaction with support groups among group members.

Methods

Searches included the CENTRAL, CINAHL, EMBASE, MEDLINE, PsycINFO and Web of Science databases from inception through 8 April 2016; reference list reviews; citation tracking of included articles; and trial registry reviews. Eligible studies were randomised controlled trials (RCTs) in any language that evaluated the effects of training programmes for peer facilitators compared with no training or alternative training formats on (1) competency or self-efficacy of peer facilitators, and (2) self-efficacy for disease management, health outcomes and satisfaction with groups of group members. The Cochrane Risk of Bias tool was used to assess risk of bias.

Results

There were 9757 unique titles/abstracts and 2 full-text publications reviewed. 1 RCT met inclusion criteria. The study evaluated the confidence and self-efficacy of cancer support group facilitators randomised to 4 months access to a website and discussion forum (N=23; low resource) versus website, discussion forum and 2-day training workshop (N=29). There were no significant differences in facilitator confidence (Hedges' g=0.16, 95% CI –0.39 to 0.71) or self-efficacy (Hedges' g=0.31, 95% CI –0.24 to 0.86). Risk of bias was unclear or high for 4 of 6 domains.

Conclusions

Well-designed and well-conducted, adequately powered trials of peer support group facilitator training programmes for patients with medical illnesses are needed.

Headaches and facial pain have been identified as the most prevalent form of pain among patients with glioblastoma multiforme, the most common malignant primary brain tumour. Despite this, minimal research has been undertaken investigating the direct and indirect impact these headaches have on their quality of life. Therefore, in this study, we aimed at gaining a personal insight into the importance and impact that these headaches have on the quality of life of patients with glioblastoma multiforme.

3 themes were identified: (1) an underlying attitude of determination and positivity; (2) impact of headache unpredictability on social interaction; (3) headaches found to act as a springboard onto thoughts regarding their disease and future.

Conclusions

While the quality of life of patients with glioblastoma multiforme is clearly multifactorial, headaches do indeed play a part for some. However, it is not the direct pain of the headache as one might expect that impacts on the quality of life of these patients, but the indirect effect of headaches through limiting patients' social lives and by serving as a painful psychological reminder of having a life-threatening illness. In clinical practice, using headache diaries for these patients may help provide a more comprehensive assessment and further aid management plans. Alongside acting as an important reminder of the potential secondary implications of this disease, suggestions for future research include quantitatively investigating whether headaches can act as a prognostic indicator for quality of life within this patient demographic and determining whether these conclusions also hold true for a wider spectrum of patients with brain tumour.

Despite recent progress, pneumonia remains the largest infectious killer of children globally. This paper describes outcomes of not treating community-diagnosed fast-breathing pneumonia on patient recovery.

Methods

We conducted an exploratory subanalysis of an observational prospective cohort study in Malawi. We recruited children (2–59 months) diagnosed by community health workers with fast-breathing pneumonia using WHO integrated community case management (iCCM) guidelines. Children were followed at days 5 and 14 with a clinical assessment of recovery. We conducted bivariate and multivariable logistic regression for the association between treatment of fast-breathing pneumonia and recovery, adjusting for potential confounders.

Results

We followed up 847 children, of whom 78 (9%) had not been given antibiotics (non-treatment). Non-treatment cases had higher baseline rates of diarrhoea, non-severe hypoxaemia and fever. Non-recovery (persistence or worsening of symptoms) was 13% and 23% at day 5 in those who did receive and those who did not receive co-trimoxazole. Non-recovery, when defined as worsening of symptoms only, at day 5 was 7% in treatment and 10% in non-treatment cases. For both definitions, combined co-trimoxazole and lumefantrine-artemether (LA) treatment trended towards protection (adjusted OR (aOR) 0.28; 95% CI 0.12 to 0.68/aOR 0.29; 95% CI 0.08 to 1.01).

Conclusion

We found that children who did not receive co-trimoxazole treatment had worse clinical outcomes; malaria co-diagnosis and treatment also play a significant role in non-recovery. Further research into non-treatment of fast-breathing pneumonia, using a pragmatic approach with consideration for malaria co-diagnosis and HIV status is needed to guide refinement of community treatment algorithms in this region.

Primary outcome—proportion of parents who reported use of the allocated study emollient every day for the duration of follow-up (12 weeks). Other feasibility outcomes—participant recruitment and retention, data collection and completeness and blinding of observers to allocation.

Interventions

Aveeno lotion, Diprobase cream, Doublebase gel, Hydromol ointment.

Results

197 children were recruited—107 by self-referral (mainly via practice mail-outs) and 90 by inconsultation (clinician consenting and randomising) pathways. Participants recruited inconsultation were younger, had more severe Patient-Oriented Eczema Measure scores and were more likely to withdraw than self-referrals. Parents of 20 (10%) of all the randomised participants reported using the allocated emollient daily for 84 days. The use of other non-study emollients was common. Completeness of data collected by parent-held daily diaries and at monthly study visits was good. Daily diaries were liked (81%) but mainly completed on paper rather than via electronic (‘app’) form. Major costs drivers were general practitioner consultations and eczema-related prescriptions. Observer unblinding was infrequent, and occurred at the baseline or first follow-up visit through accidental disclosure.

Conclusions

It is feasible in a primary care setting to recruit and randomise young children with eczema to emollients, follow them up and collect relevant trial data, while keeping observers blinded to their allocation. However, reported use of emollients (study and others) has design implications for future trials.

In most developed countries, substantial disparities exist in access to mental health services for black and minority ethnic (BME) populations. We sought to determine perceived barriers to accessing mental health services among people from these backgrounds to inform the development of effective and culturally acceptable services to improve equity in healthcare.

Design and setting

Qualitative study in Southeast England.

Participants

26 adults from BME backgrounds (13 men, 13 women; aged >18 years) were recruited to 2 focus groups. Participants were identified through the registers of the Black and Minority Ethnic Community Partnership centre and by visits to local community gatherings and were invited to take part by community development workers. Thematic analysis was conducted to identify key themes about perceived barriers to accessing mental health services.

Results

Participants identified 2 broad themes that influenced access to mental health services. First, personal and environmental factors included inability to recognise and accept mental health problems, positive impact of social networks, reluctance to discuss psychological distress and seek help among men, cultural identity, negative perception of and social stigma against mental health and financial factors. Second, factors affecting the relationship between service user and healthcare provider included the impact of long waiting times for initial assessment, language barriers, poor communication between service users and providers, inadequate recognition or response to mental health needs, imbalance of power and authority between service users and providers, cultural naivety, insensitivity and discrimination towards the needs of BME service users and lack of awareness of different services among service users and providers.

Conclusions

People from BME backgrounds require considerable mental health literacy and practical support to raise awareness of mental health conditions and combat stigma. There is a need for improving information about services and access pathways. Healthcare providers need relevant training and support in developing effective communication strategies to deliver individually tailored and culturally sensitive care. Improved engagement with people from BME backgrounds in the development and delivery of culturally appropriate mental health services could facilitate better understanding of mental health conditions and improve access.

To characterise the current usage of chemoprevention agents among hospitalised women who are at higher risk for breast cancer.

Study design

A cross-sectional study.

Setting

Academic hospital at Baltimore.

Participants

A bedside survey of 250 women aged 50–75 years was conducted who were cancer-free at the time of study enrolment and hospitalised to a general medicine service. Reproductive history, family history for breast cancer, chemopreventive agents use and medical comorbidities data was collected for all patients. 2 and t-tests were used to analyse population characteristics.

Primary outcome measures

Prevalence of women at high risk for developing breast cancer (5-year Gail risk score ≥1.7) and their chemopreventive agent use.

Results

Mean age for the study population was 61.5 years (SD 7.5), and mean 5-year Gail risk score was 1.67 (SD 0.88). A third of study population was at high risk for breast cancer. None of the high-risk women (0%) were taking chemoprevention for breast cancer risk reduction, and 23% were at very high risk with 5-year Gail score ≥3%. These women were not recognised as being high risk by their hospital providers and none were referred to the high-risk breast cancer clinics following discharge.

Conclusions

Many hospitalised women are at high risk for breast cancer and we could not identify even a single woman who was using chemoprevention for risk reduction. Current chemoprevention guidelines may be falling short in their dissemination and implementation. Since women at high risk for breast cancer may only interface with the healthcare system at select points, all healthcare providers must be willing and able to do risk assessment. For those identified to be at high risk, providers must then either engage in chemopreventive counselling or refer patients to providers who are more comfortable working with patients on this critical decision.

Multimorbidity is prevalent, and knowledge regarding its aetiology is limited. The general pathogenic impact of adverse life experiences, comprising a wide-ranging typology, is well documented and coherent with the concept allostatic overload (the long-term impact of stress on human physiology) and the notion embodiment (the conversion of sociocultural and environmental influences into physiological characteristics). Less is known about the medical relevance of subtle distress or unease. The study aim was to prospectively explore the associations between existential unease (coined as a meta-term for the included items) and multimorbidity.

Setting

Our data are derived from an unselected Norwegian population, the Nord-Trøndelag Health Study, phases 2 (1995–1997) and 3 (2006–2008), with a mean of 11 years follow-up.

Participants

The analysis includes 20 365 individuals aged 20–59 years who participated in both phases and was classified without multimorbidity (with 0–1 disease) at baseline.

Methods

From HUNT2, we selected 11 items indicating ‘unease’ in the realms of self-esteem, well-being, sense of coherence and social relationships. Poisson regressions were used to generate relative risk (RR) of developing multimorbidity, according to the respondents' ease/unease profile.

Results

A total of 6277 (30.8%) participants developed multimorbidity. They were older, more likely to be women, smokers and with lower education. 10 of the 11 ‘unease’ items were significantly related to the development of multimorbidity. The items ‘poor self-rated health’ and ‘feeling dissatisfied with life’ exhibited the highest RR, 1.55 and 1.44, respectively (95% CI 1.44 to 1.66 and 1.21 to 1.71). The prevalence of multimorbidity increased with the number of ‘unease’ factors, from 26.7% for no factor to 49.2% for 6 or more.

Conclusions

In this prospective study, ‘existential unease’ was associated with the development of multimorbidity in a dose–response manner. The finding indicates that existential unease increases people's vulnerability to disease, concordant with current literature regarding increased allostatic load.

Concerns exist that e-cigarettes may be a gateway to traditional cigarettes and/or (re)normalise teenage smoking. This qualitative study explores how teenagers in the UK currently perceive e-cigarettes and how and why they do or do not use them.

Design

16 focus groups were conducted across the UK between November 2014 and February 2015, with 83 teenagers aged 14–17. All discussions were digitally recorded, transcribed verbatim, imported into NVivo 10 and thematically analysed.

Results

Teenagers generally agreed that e-cigarettes are useful products for smokers, including teenage smokers, to quit or reduce traditional cigarette use. Concerns were expressed about lack of information on their precise ingredients and any unknown risks for users and bystanders. However, teenagers typically viewed e-cigarettes as substantially less harmful than traditional cigarettes. They perceived e-cigarettes as attractive, with products described as ‘fun’ and having ‘great flavourings’. Seeing websites or social media featuring e-cigarettes, especially YouTube ‘vaping tricks’, prompted some experimentation and imitation. E-cigarettes were used in a variety of situations, including at parties or when they could not smoke traditional cigarettes. A very few participants suggested covert use was a possibility and that e-cigarettes might help maintain a fledgling nicotine habit.

Conclusions

Teenagers support the use of e-cigarettes as smoking cessation aids for established adult smokers. However, they engage with these products differently from adults, with the novel hypothesis that covert use could potentially reinforce traditional cigarette smoking requiring further investigation. Policy responses should more clearly meet the needs of young people, as well as helping established adult smokers.

The increasing number of low-acuity visits to emergency departments (ED) is an important issue in Germany, despite the fact that all costs of inpatient and outpatient treatment are covered by mandatory health insurance. We aimed to explore the motives of patients categorised with low-acuity conditions for visiting an ED.

Methods

We conducted a qualitative study in two urban and one rural ED. We recruited a purposive sample of adults, who were assigned to the lowest two categories in the Manchester triage system. One-to-one interviews took place in the ED during patients' waiting time for treatment. Interview transcripts were analysed using the qualitative data management software MAXQDA. A qualitative content analysis approach was taken to identify motives and to compare the rural with the urban sites.

Results

A total of 86 patients were asked to participate; of these, n=15 declined participation and n=7 were excluded because they were admitted as inpatients, leaving a final sample of 40 female and 24 male patients. We identified three pathways leading to an ED visit: (1) without primary care contact, (2) after unsuccessful attempts to see a resident specialist or general practitioner (GP) and (3) recommendation to visit the ED by an outpatient provider. The two essential motives were (1) convenience and (2) health anxiety, triggered by time constraints and focused usage of multidisciplinary medical care in a highly equipped setting. All participants from the rural region were connected to a GP, whom they saw more or less regularly, while more interviewees from the urban site did not have a permanent GP. Still, motives to visit the ED were in general the same.

Conclusions

We conclude that the ED plays a pivotal role in ambulatory acute care which needs to be recognised for adequate resource allocation.

To investigate the free sugars and calorie content of carbonated sugar-sweetened beverages (CSSB) available in the main UK supermarkets.

Study design

We carried out a cross-sectional survey in 2014 of 169 CSSB.

Methods

The free sugars (sugars g/100 mL) and calorie (kcal/100 mL) were collected from product packaging and nutrient information panels of CSSB available in 9 main UK supermarkets.

Results

The average free sugars content in CSSB was 30.1±10.7 g/330 mL, and 91% of CSSB would receive a ‘red’ (high) label for sugars per serving. There was a large variation in sugars content between different flavours of CSSB and within the same type of flavour ranging from 3.3 to 52.8 g/330 mL. On average, ginger beer (38.5±9.9 g/330 mL) contained the highest amounts of sugars and ginger ale (22.9±7.7 g/330 mL) contained the lowest. Cola flavour is the most popular flavour in the UK with an average free sugars content of 35.0±1.1 g/330 mL. On average, the supermarket own brand contained lower levels of sugars than branded products (27.9±10.6 vs 31.6±10.6 g/330 mL, p=0.02). The average calorie content in CSSB was 126.1±43.5 kcal/330 mL. Cola flavour had a calorie content of 143.5±5.2 kcal/330 mL. Among the 169 products surveyed, 55% exceeded the maximum daily recommendation for free sugars intake (30 g) per 330 mL.

Conclusions

Free sugars content of CSSB in the UK is high and is a major contributor to free sugars intake. There is a wide variation in the sugars content of CSSB and even within the same flavour of CSSB. These findings demonstrate that the amount of free sugars added to CSSB can be reduced without technical issues, and there is an urgent need to set incremental free sugars reduction targets. A reduction in sugars content and overall CSSB consumption will be very beneficial in reducing obesity, type 2 diabetes and dental caries.

Elevated levels of alcohol consumption among university students are well documented. Policymakers have attempted to combat this issue at a university, national and international level. Tailoring public health policy to effectively tackle alcohol use is crucial. Using Q-methodology, the current study aims to develop a typology of alcohol consumption in the Irish university student population.

Setting

A large Irish university.

Participants

Hundreds of possible statements on types of consumption were generated from a systematic review and a set of one-on-one interviews. These were reduced to 36 statements, 6 statements which define each of the 6 previously defined consumption types. Participants were advised to scan through the 36 statements and fill the statements into a ‘forced choice, standardised distribution’. Following this, a 45–90 min interview was conducted with students to illuminate subjectivity surrounding alcohol consumption. Analysis was conducted using PQ Method and NVivo software. Principal component analysis, followed by varimax rotation, was conducted to uncover the final factor information.

Results

In total, 43 students completed the Q-study: 19 men and 24 women. A typology describing 4 distinct groupings of alcohol consumer was uncovered: the guarded drinker, the calculated hedonist, the peer-influenced drinker and the inevitable binger. Factor loadings of each of the consumer groupings were noted for type description.

Conclusions

This is the first study to propose ideal types of alcohol consumption among a university student population. Further research is required to investigate the degree to which each of these ideal types is subscribed. However, this typology, in addition to informing public policy and strategies, will be a valuable analytic tool in future research.

The aim of this study was to compare outcomes when the upper and lower thoracic regions were used as the site of proximal instrumentation to treat adult spinal deformity.

Methods

MEDLINE, Embase and Cochrane library searches were performed to identify studies that compared outcome measures when the upper and lower thoracic vertebrae (UTV and LTV, respectively) were used as the site of proximal instrumentation. The weighted mean difference (WMD) was calculated for continuous outcomes, and the relative risk (RR) was calculated for dichotomous outcomes.

Results

Seven articles (n=554 patients) met the final inclusion criteria, and we compared the outcome measures of a long fusion extending to the upper and lower thoracic regions. The pooled analysis revealed that extending fixation into the upper thoracic region decreased the risk of proximal junctional kyphosis (PJK) revision surgery (RR: 0.36, 95% CI 0.14 to 0.90, p<0.05). The operation time (WMD: 0.93, 95% CI 0.48 to 1.39, p<0.05) and estimated blood loss (WMD: 0.59, 95% CI 0.33 to 0.85, p<0.05) were significantly greater in the UTV group than in the LTV group. No significant differences were found in the Scoliosis Research Society pain, self-image, function, mental health, subtotal, satisfaction or total scores; the total number of complications or the total number of revision surgeries.

Conclusions

Long posterior fixation extending into the upper thoracic region reduces the incidence of revision surgery related to PJK; however, it increased the operative level resulting in a longer operative time and greater estimated blood loss. This initial analysis indicates that extending fixation to the upper thoracic region is appropriate for patients who are likely to develop PJK following initial scoliosis correction.

To determine the influence of age and gender, respectively, on the association between employment status and body mass index (BMI) in Korean adults using a large, nationally representative sample.

Design

Cross-sectional study.

Setting

South Korea.

Participants

7228 from fourth wave of the Korean Longitudinal Study of Aging (KLoSA), the survey's short form and year: ‘KLoSA 2012’.

Main outcome measures

BMI.

Results

BMI among the employed was higher than among the unemployed for those under 60. In terms of gender, employed men reported higher BMI than their unemployed counterparts, whereas employed women reported lower BMI than did unemployed women.

Conclusions

Employment status showed varying impacts on obesity by age and gender. Both unemployment at or after 60, as well as unemployment among women, is associated with increased BMI compared with unemployment among younger individuals or men, respectively.

Social determinants can have a major impact on health and as a consequence substantial inequalities are seen between and within countries. The study of inequalities between countries relies on having accurate and consistent measures of deprivation across the country borders. However, in the UK most socioeconomic deprivation measures are not comparable between countries. We give a method of adjusting the Indices of Multiple Deprivation (IMD) for use across the UK, describe the deprivation of each UK country, and show the problems introduced by naïvely using country-specific deprivation measures in a UK-wide analysis of mortality rates.

Setting/participants

42 148 geographic areas covering the population of the UK.

Outcome measures

Adjusted IMD scores based on the income and employment domains of country-specific IMD scores, adjusting for the contribution of other domains. The mortality rate among people aged under 75 years standardised to the UK age structure was compared between country-specific and UK-adjusted IMD quintiles.

Results

Of the constituent countries of the UK, Northern Ireland was the most deprived with 37% of the population living in areas in the most deprived fifth of the UK, followed by Wales with 22% of the population living in the most deprived fifth of the UK. England and Scotland had similar levels of deprivation. Deprivation-specific mortality rates were similar in England and Wales. Northern Ireland had lower mortality rates than England for each deprivation group, with similar differences for each group. Scotland had higher mortality rates than England for each deprivation group, with larger differences for more deprived groups.

Conclusions

Analyses of between-country and within-country inequalities by socioeconomic position should use consistent measures; failing to use consistent measures may give misleading results. The published adjusted IMD scores we describe allow consistent analysis across the UK.

Although metabolic syndrome correlates with erosive oesophagitis, few studies have examined the association between non-alcoholic fatty liver disease (NAFLD), associated with obesity and insulin resistance as metabolic syndrome, and erosive oesophagitis. The possible gender differences in risk factors of erosive oesophagitis should be considered. This study aimed to determine the concomitant effects of NAFLD and metabolic syndrome on erosive oesophagitis with respect to gender.

Design, setting, participants and outcome measures

This cross-sectional study, conducted between January 2000 and August 2009, included 12 090 participants from the health examination center of a tertiary hospital. NAFLD was diagnosed according to ultrasonographic findings after excluding participants with excessive alcohol consumption or other liver diseases. Metabolic syndrome was determined using the revised National Cholesterol Education Program Adult Treatment Panel III criteria. Erosive oesophagitis was defined according to the Los Angeles classification by oesophagogastroduodenoscopy.

Results

On the basis of the oesophagogastroduodenoscopic findings, the prevalence of erosive oesophagitis was 20.1% (n=1427/7110) and 9.9% (n=477/4842) in males and females, respectively. After adjusting for other variables, metabolic syndrome (OR 1.26; 95% CI 1.09 to 1.45) but not NAFLD (OR 1.14; 95% CI 0.98 to 1.30) significantly correlated with erosive oesophagitis in males, while NAFLD (OR 1.50; 95% CI 1.21 to 1.86) but not metabolic syndrome (OR 1.24; 95% CI 0.94 to 1.63) positively correlated with erosive oesophagitis in females.

Conclusions

The detrimental effect on erosive oesophagitis is greater by metabolic syndrome than by NAFLD in males but greater by NAFLD than by metabolic syndrome in females.

Systematic review and meta-analysis of published observational cohort studies. To quantify the increased risk smokers have of experiencing a delayed and/or non-union in fractures, spinal fusion, osteotomy, arthrodesis or established non-unions.

Observational cohort studies that reported adult smokers and non-smokers with delayed and/or non-union or time to union of the fracture, spinal fusion, osteotomy, arthrodesis or established non-union were eligible.

Data extraction and outcome measures

2 authors screen titles, abstracts and full papers. Data were extracted by 1 author and checked independently by a second. The relative risk ratios of smoking versus non-smoking and the mean difference in time to union patients developing a delayed and/or non-union were calculated.

Results

The search identified 3013 articles; of which, 40 studies were included. The meta-analysis of 7516 procedures revealed that smoking is linked to an increased risk of delayed and/or non-union. When considered collectively, smokers have 2.2 (1.9 to 2.6) times the risk of experiencing delayed and/or non-union. In all the subgroups, the increased risk was always ≥1.6 times that of non-smokers. In the patients where union did occur, it was a longer process in the smokers. The data from 923 procedures were included and revealed an increase in time to union of 27.7 days (14.2 to 41.3).

Conclusions

Smokers have twice the risk of experiencing a non-union after fracture, spinal fusion, osteotomy, arthrodesis or treatment of non-union. Time to union following fracture, osteotomy, arthrodesis or treatment of an established non-union is longer in smokers. Smokers should be encouraged to abstain from smoking to improve the outcome of these orthopaedic treatments.

To assess the methodology and quality of evidence of systematic reviews and meta-analyses of traditional Chinese medical nursing (TCMN) interventions in Chinese journals. These interventions include acupressure, massage, Tai Chi, Qi Gong, electroacupuncture and use of Chinese herbal medicines—for example, in enemas, foot massage and compressing the umbilicus.

Design

A systematic literature search for systematic reviews and meta-analyses of TCMN interventions was performed. Review characteristics were extracted. The methodological quality and the quality of the evidence were evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) approaches.

Result

We included 20 systematic reviews and meta-analyses, and a total of 11 TCMN interventions were assessed in the 20 reviews. The compliance with AMSTAR checklist items ranged from 4.5 to 8 and systematic reviews/meta-analyses were, on average, of medium methodological quality. The quality of the evidence we assessed ranged from very low to moderate; no high-quality evidence was found. The top two causes for downrating confidence in effect estimates among the 31 bodies of evidence assessed were the risk of bias and inconsistency.

Conclusions

There is room for improvement in the methodological quality of systematic reviews/meta-analyses of TCMN interventions published in Chinese journals. Greater efforts should be devoted to ensuring a more comprehensive search strategy, clearer specification of the interventions of interest in the eligibility criteria and identification of meaningful outcomes for clinicians and patients (consumers). The overall quality of evidence among reviews remains suboptimal, which raise concerns about their roles in influencing clinical practice. Thus, the conclusions in reviews we assessed must be treated with caution and their roles in influencing clinical practice should be limited. A critical appraisal of systematic reviews/meta-analyses of TCMN interventions is particularly important to provide sound guidance for TCMN.

To assess the efficacy of the Diabetes Medication Choice Decision Aid among patients with type 2 diabetes in Greece.

Design

Open-label cluster randomised controlled trial.

Setting

Primary and secondary care practices across Greece.

Participants

5 sites allocated to the decision aid (n=101 patients) and 4 sites to control (n=103 patients).

Intervention

Clinicians and patients in the intervention arm used a decision aid, based on outcomes that both consider important when choosing among antihyperglycaemic medications. Patients in the control arm received usual care.

Outcome measures

The primary outcome was patient's level of decisional comfort after the initial clinical encounter. Secondary outcomes included patient's knowledge about type 2 diabetes and medications, and patient's and clinician's satisfaction. Adherence to prescribed antihyperglycaemic medication and change in glycated haemoglobin were assessed at 24 weeks.

Results

Patients in both arms had similar scores in overall decisional comfort (mean difference between the usual care and decision aid arms –6.9, 95% CI –21.5 to 7.7) and its subscales. Patients' knowledge was high in both arms (mean difference 2.3%, 95% CI –15.7% to 20.4%). Patients and clinicians in both groups were equally satisfied with the decision-making. No significant difference in medication adherence and glycaemic control was found across arms. Clinicians found the decision aid useful and reported that its integration in their daily routine was easy.

Conclusions

The decision aid was implemented and positively received in the clinical setting in Greece, in line with the patient-centred approach endorsed by current guidelines. However, this trial yielded imprecise results in terms of patient outcomes. Further research is needed to investigate the interaction between the patient and the clinician in order to clarify the association between the use of decision aids and implementation of shared decision-making.

Emergency admission is associated with the potential for adverse events in older people and risk prediction models are available to identify those at highest risk of admission. The aim of this study was to externally validate and compare the performance of the Probability of repeated admission (Pra) risk model and a modified version (incorporating a multimorbidity measure) in predicting emergency admission in older community-dwelling people.

Setting

15 general practices (GPs) in the Republic of Ireland.

Participants

n=862, ≥70 years, community-dwelling people prospectively followed up for 2 years (2010–2012). Exposure: Pra risk model (original and modified) calculated for baseline year where ≥0.5 denoted high risk (patient questionnaire, GP medical record review) of future emergency admission.

Of 862 patients, a total of 154 (18%) had ≥1 emergency admission(s) in the follow-up year. 63 patients (7%) were classified as high risk by the original Pra and of these 26 (41%) were admitted. The modified Pra classified 391 (45%) patients as high risk and 103 (26%) were subsequently admitted. Both models demonstrated only poor discrimination (original Pra: c-statistic 0.65 (95% CI 0.61 to 0.70); modified Pra: c-statistic 0.67 (95% CI 0.62 to 0.72)). When categorised according to risk-category model, specificity was highest for the original Pra at cut-point of ≥0.5 denoting high risk (95%), and for the modified Pra at cut-point of ≥0.7 (95%). Both models overestimated the number of admissions across all risk strata.

Conclusions

While the original Pra model demonstrated poor discrimination, model specificity was high and a small number of patients identified as high risk. Future validation studies should examine higher cut-points denoting high risk for the modified Pra, which has practical advantages in terms of application in GP. The original Pra tool may have a role in identifying higher-risk community-dwelling older people for inclusion in future trials aiming to reduce emergency admissions.

Historically, women have lower all-cause mortality than men. It is less understood that sex differences have been converging, particularly among certain subgroups and causes. This has implications for public health and health system planning. Our objective was to analyse contemporary sex differences over a 20-year period.

Methods

We analysed data from a population-based death registry, the Ontario Registrar's General Death file, which includes all deaths recorded in Canada's most populous province, from 1992 to 2012 (N=1 710 080 deaths). We calculated absolute and relative mortality sex differences for all-cause and cause-specific mortality, age-adjusted and age-specific, including the following causes: circulatory, cancers, respiratory and injuries. We used negative-binomial regression of mortality on socioeconomic status with direct age adjustment for the overall population.

Results

In the 20-year period, age-adjusted mortality dropped 39.2% and 29.8%, respectively, among men and women. The age-adjusted male-to-female mortality ratio dropped 41.4%, falling from 1.47 to 1.28. From 2000 onwards, all-cause mortality rates of high-income men were lower than those seen among low-income women. Relative mortality declines were greater among men than women for cancer, respiratory and injury-related deaths. The absolute decline in circulatory deaths was greater among men, although relative deciles were similar to women. The largest absolute mortality gains were seen among men over the age of 85 years.

Conclusions

The large decline in mortality sex ratios in a Canadian province with universal healthcare over two decades signals an important population shift. These narrowing trends varied according to cause of death and age. In addition, persistent social inequalities in mortality exist and differentially affect men and women. The observed change in sex ratios has implications for healthcare and social systems.

Atmospheric fine particulate matter (PM2.5) has multiple adverse effects on human health. Global atmospheric levels of PM2.5 increased by 0.55 μg/m3/year (2.1%/year) from 1998 through 2012. There is evidence of a causal relationship between atmospheric PM2.5 and breast cancer (BC) incidence, but few studies have investigated BC mortality and atmospheric PM2.5. We investigated BC mortality in relation to atmospheric PM2.5 levels among patients living in Varese Province, northern Italy.

Methods

We selected female BC cases, archived in the local population-based cancer registry, diagnosed at age 50–69 years, between 2003 and 2009. The geographic coordinates of each woman's place of residence were identified, and individual PM2.5 exposures were assessed from satellite data. Grade, stage, age at diagnosis, period of diagnosis and participation in BC screening were potential confounders. Kaplan-Meir and Nelson-Aalen methods were used to test for mortality differences in relation to PM2.5 quartiles. Multivariable Cox proportional hazards modelling estimated HRs and 95% CIs of BC death in relation to PM2.5 exposure.

Results

Of 2021 BC cases, 325 died during follow-up to 31 December 2013, 246 for BC. Risk of BC death was significantly higher for all three upper quartiles of PM2.5 exposure compared to the lowest, with HRs of death: 1.82 (95% CI 1.15 to 2.89), 1.73 (95% CI 1.12 to 2.67) and 1.72 (95% CI 1.08 to 2.75).

Conclusions

Our study indicates that the risk of BC mortality increases with PM2.5 exposure. Although additional research is required to confirm these findings, they are further evidence that PM2.5 exposure is harmful and indicate an urgent need to improve global air quality.

]]>2016-11-14T04:44:31-08:00info:doi/10.1136/bmjopen-2016-012580hwp:master-id:bmjopen;bmjopen-2016-012580British Medical Journal Publishing Group2016-11-14Research611e012580e012580http://bmjopen.bmj.com/cgi/content/short/6/11/e012799?rss=1
Diagnostic accuracy studies are, like other clinical studies, at risk of bias due to shortcomings in design and conduct, and the results of a diagnostic accuracy study may not apply to other patient groups and settings. Readers of study reports need to be informed about study design and conduct, in sufficient detail to judge the trustworthiness and applicability of the study findings. The STARD statement (Standards for Reporting of Diagnostic Accuracy Studies) was developed to improve the completeness and transparency of reports of diagnostic accuracy studies. STARD contains a list of essential items that can be used as a checklist, by authors, reviewers and other readers, to ensure that a report of a diagnostic accuracy study contains the necessary information. STARD was recently updated. All updated STARD materials, including the checklist, are available at http://www.equator-network.org/reporting-guidelines/stard. Here, we present the STARD 2015 explanation and elaboration document. Through commented examples of appropriate reporting, we clarify the rationale for each of the 30 items on the STARD 2015 checklist, and describe what is expected from authors in developing sufficiently informative study reports.
]]>2016-11-14T04:44:31-08:00info:doi/10.1136/bmjopen-2016-012799hwp:master-id:bmjopen;bmjopen-2016-012799British Medical Journal Publishing Group2016-11-14Research611e012799e012799http://bmjopen.bmj.com/cgi/content/short/6/11/e013728?rss=1
Background

The main barrier to optimal effect in many established population-based screening programmes against cervical cancer is low participation. In Norway, a routine health service integrated population-based screening programme has been running since 1995, using open invitations and reminders. The aim of this randomised health service study was to pilot scheduled appointments and assess their potential for increased participation.

Methods

Within the national screening programme, we randomised 1087 women overdue for screening to receive invitations with scheduled appointments (intervention) or the standard open reminders (control). Letters were sent 2–4 weeks before the scheduled appointments at three centres: a midwife clinic, a public healthcare centre and a general practitioner centre. The primary outcome was participation at 6 months of follow-up. Secondary outcomes were participation at 1 and 3 months. Risk ratios (RRs) overall, and stratified by screening centre, age group and previous participation, were calculated using log-binomial regression.

Results

At 6 months, 20% of the 510 women in the control group and 37% of the 526 women in the intervention group had participated in screening, excluding 51 women in total from analysis due to participation just before invitation and therefore not yet visible in the central records. The RR for participation at 6 months was 1.9 (95% CI 1.5 to 2.3). There was no significant heterogeneity between centres or age groups. Participation increased among women both with (RR 1.7; 95% CI 1.4 to 2.1) and without (RR 3.5; 95% CI 1.3 to 9.2) previous participation. The RRs for participation at 1 and 3 months were 4.0 (95% CI 2.6 to 6.2) and 2.7 (95% CI 2.1 to 3.5), respectively.

Conclusions

Scheduled appointments increased screening participation consistently across all target ages and screening centres among women overdue for screening. Participation increased also among women with no previous records of cervical screening.

Atopic dermatitis (AD) is an inflammatory skin disorder with a childhood prevalence reaching 20%. An estimated 50% of patients have a life-long chronic course. The purpose of this study was to estimate the risk of first-time myocardial infarction (MI) in patients with AD compared with a general population cohort.

Design

Cohort study.

Setting

Denmark.

Participants

Using population-based medical registries, we identified individuals born in Denmark from 1947 to 1983 with at least two hospital-diagnoses of AD following inpatient admissions or hospital-based outpatient visits at any age from 1977 to 2013. Individuals with AD were matched with general population controls (10:1) for birth-year and gender. Unique personal identifiers permitted unambiguous data linkage.

Primary outcome measures

Follow-up began on the date of AD diagnosis (index date for general population controls) and continued until death, emigration, MI or the year 2013. We computed the 15-year-cumulative incidence of MI following a diagnosis of AD. Comparing patients with AD with the general population cohort, we computed HRs of MI presented with 95% CIs and adjusted for history of diabetes mellitus, hypertension, hyperlipidaemia or stroke, educational level, birth-year and sex.

Results

We identified 4814 patients diagnosed with AD. The cumulative incidence of MI was 0.6% for patients with AD and 0.4% for their matched controls. The corresponding adjusted HR was 1.74 (1.21 to 2.49). The HR for patients who were not in need of systemic treatment was 1.58 (1.02 to 2.45) and it was 2.40 (1.27 to 4.45) for those who were treated with azathioprine, methotrexate or cyclosporine.

Conclusions

Hospital-diagnosed AD was associated with increased risk of MI compared with the general population.

Township hospitals (THs) are important components of the three-tier rural healthcare system of China. However, the efficiency and productivity of THs have been questioned since the healthcare reform was implemented in 2009. The objective of this study is to analyse the efficiency and productivity changes in THs before and after the reform process.

Setting and participants

A total of 48 sample THs were selected from the Xiaogan Prefecture in Hubei Province from 2008 to 2014.

Outcome measures

First, bootstrapping data envelopment analysis (DEA) was performed to estimate the technical efficiency (TE), pure technical efficiency (PTE) and scale efficiency (SE) of the sample THs during the period. Second, the bootstrapping Malmquist productivity index was used to calculate the productivity changes over time.

Results

The average TE, PTE and SE of the sample THs over the 7-year period were 0.5147, 0.6373 and 0.7080, respectively. The average TE and PTE increased from 2008 to 2012 but declined considerably after 2012. In general, the sample THs experienced a negative shift in productivity from 2008 to 2014. The negative change was 2.14%, which was attributed to a 23.89% decrease in technological changes (TC). The sample THs experienced a positive productivity shift from 2008 to 2012 but experienced deterioration from 2012 to 2014.

Conclusions

There was considerable space for TE improvement in the sample THs since the average TE was relatively low. From 2008 to 2014, the sample THs experienced a decrease in productivity, and the adverse alteration in TC should be emphasised. In the context of healthcare reform, the factors that influence TE and productivity of THs are complex. Results suggest that numerous quantitative and qualitative studies are necessary to explore the reasons for the changes in TE and productivity.

To describe the frequency and characterise the nature of patient safety events in paediatric out-of-hospital airway management.

Methods

We conducted a retrospective cross-sectional medical record review of all ‘lights and sirens’ emergency medicine services transports from 2008 to 2011 in patients <18 years of age in the Portland Oregon metropolitan area. A chart review tool (see online ) was adapted from landmark patient safety studies and revised after pilot testing. Expert panels of physicians and paramedics performed blinded reviews of each chart, identified safety events and described their nature. The primary outcomes were presence and severity of patient safety events related to airway management including oxygen administration, bag-valve-mask ventilation (BVM), airway adjuncts and endotracheal intubation (ETI).

Results

From the 11 328 paediatric transports during the study period, there were 497 ‘lights and sirens’ (code 3) transports (4.4%). 7 transports were excluded due to missing data. Of the 490 transports included in the analysis, 329 had a total of 338 airway management procedures (some had more than 1 procedure): 61.6% were treated with oxygen, 15.3% with BVM, 8.6% with ETI and 2% with airway adjuncts. The frequency of errors was: 21% (71/338) related to oxygen use, 9.8% (33/338) related to BVM, 9.5% (32/338) related to intubation and 0.9% (3/338) related to airway adjunct use. 58% of intubations required 3 or more attempts or failed altogether. Cardiac arrest was associated with higher odds of a severe error.

Conclusions

Errors in paediatric out-of-hospital airway management are common, especially in the context of intubations and during cardiac arrest.

Optimising uptake of colorectal cancer (CRC) screening is important to achieve projected health outcomes. Population-based screening by flexible sigmoidoscopy (FS) was introduced in England in 2013 (NHS Bowel scope screening). Little is known about reactions to the invitation to participate in FS screening, as offered within the context of the Bowel scope programme. We aimed to investigate responses to the screening invitation to inform understanding of decision-making, particularly in relation to non-participation in screening.

Design

Qualitative analysis of semistructured in-depth interviews and written accounts.

Participants and setting

People from 31 general practices in the North East and East of England invited to attend FS screening as part of NHS Bowel scope screening programme were sent invitations to take part in the study. We purposively sampled interviewees to ensure a range of accounts in terms of beliefs, screening attendance, sex and geographical location.

Results

20 screeners and 25 non-screeners were interviewed. Written responses describing reasons for, and circumstances surrounding, non-participation from a further 28 non-screeners were included in the analysis. Thematic analysis identified a range of reactions to the screening invitation, decision-making processes and barriers to participation. These include a perceived or actual lack of need; inability to attend; anxiety and fear about bowel preparation, procedures or hospital; inability or reluctance to self-administer an enema; beliefs about low susceptibility to bowel cancer or treatment and understanding of harm and benefits. The strength, rather than presence, of concerns about the test and perceived need for reassurance were important in the decision to participate for screeners and non-screeners. Decision-making occurs within the context of previous experiences and day-to-day life.

Conclusions

Understanding the reasons for non-participation in FS screening can help inform strategies to improve uptake and may be transferable to other screening programmes.

All year 9 students in intervention schools were exposed to the intervention; over all schools 77% of eligible students were measured. 71% boys and 74% girls found GoActive ‘fun’; 38% boys and 32% girls said it increased confidence, and 64% boys and 59% girls said they would continue with a GoActive activity. Suggested improvements included more mentorship; improved training; streamlined points recording. Pilot results indicated potential effectiveness ((adjusted mean difference (95% CI) p value; MVPA mins; 5.1 (1.1 to 9.2) p=0.014)) and suggest recruitment of 16 schools (2400 adolescents) for a full trial. Compared with control, intervention students reported greater peer support 0.5 (0.1 to 0.9) p=0.03, well-being 1.8 (0.1 to 3.4) p=0.04 but no difference in shyness/sociability. Participation in activity types approached significance (intervention group 2.3 (–0.2 to 4.7) p=0.07 more activity types).

Conclusions

Results suggest feasibility and indicate potential effectiveness of GoActive to increase MVPA and support a fully powered evaluation of effectiveness and cost-effectiveness. Process evaluation data were used to refine GoActive prior to a full trial.

The aim of this study was to analyse the clustering of multiple health-related behaviours among adolescents and describe which socio-demographic characteristics are associated with these patterns.

Design

Cross-sectional study.

Setting

Brazilian schools assessed by the National Survey of School Health (PeNSE, 2012).

Participants

104 109 Brazilian ninth-grade students from public and private schools (response rate=82.7%).

Methods

Exploratory and confirmatory factor analyses were performed to identify behaviour clustering and linear regression models were used to identify socio-demographic characteristics associated with each one of these behaviour patterns.

Results

We identified a good fit model with three behaviour patterns. The first was labelled ‘problem-behaviour’ and included aggressive behaviour, alcohol consumption, smoking, drug use and unsafe sex; the second was labelled ‘health-compromising diet and sedentary behaviours’ and included unhealthy food indicators and sedentary behaviour; and the third was labelled ‘health-promoting diet and physical activity’ and included healthy food indicators and physical activity. No differences in behaviour patterns were found between genders. The problem-behaviour pattern was associated with male gender, older age, more developed region (socially and economically) and public schools (compared with private). The ‘health-compromising diet and sedentary behaviours’ pattern was associated with female gender, older age, mothers with higher education level and more developed region. The ‘health-promoting diet and physical activity’ pattern was associated with male gender and mothers with higher education level.

Conclusions

Three health-related behaviour patterns were found among Brazilian adolescents. Interventions to decrease those negative patterns should take into account how these behaviours cluster together and the individuals most at risk.

To assess the feasibility of prospectively collecting biological samples (urine) from palliative care patients in the last weeks of life.

Setting

A 30-bedded specialist hospice in the North West of England.

Participants

Participants were adults with a diagnosis of advanced disease and able to provide written informed consent.

Method

Potential participants were identified by a senior clinician over a 12-week period in 2014. They were then approached by a researcher and invited to participate according to a developed recruitment protocol.

Outcomes

Feasibility targets included a recruitment rate of 50%, with successful collection of samples from 80% who consented.

Results

A total of 58 patients were approached and 33 consented (57% recruitment rate). Twenty-five patients (43%) were unable to participate or declined; 10 (17%) became unwell, too fatigued, lost capacity, died or were discharged home; and 15 (26%) refused, usually these patients had distressing pain, low mood or profound fatigue. From the 33 recruited, 20 participants provided 128 separate urine samples, 12 participants did not meet the inclusion criteria at the time of consent and 1 participant was unable to provide a sample. The criterion for a urinary catheter was removed for the latter 6 weeks. The collection rate during the first 6 weeks was 29% and 93% for the latter 6 weeks. Seven people died while the study was ongoing, and another 4 participants died in the following 4 weeks.

Conclusions

It is possible to recruit and collect multiple biological samples over time from palliative care patients in the last weeks and days of life even if they have lost capacity. Research into the biological changes at the end of life could develop a greater understanding of the biology of the dying process. This may lead to improved prognostication and care of patients towards the end of life.

This study describes the impact of traumatic brain injury (TBI) and hazardous drinking on mental health and behavioural issues among Ontario adolescents. In particular, we assessed the incremental co-occurrence of hazardous drinking with a history of TBI, in comparison to experiencing just one of these conditions.

Methods

A cross-sectional subsample of 3130 Ontario adolescents attending grades 9–12, and aged 10–21 were surveyed in 2013 as a part of the Centre for Addiction and Mental Health's Ontario Student Drug Use and Health Survey. Recent (past year) and former (lifetime and excluding the last year) TBI were defined as trauma to the head that resulted in loss of consciousness for at least 5 min or overnight hospitalisation. Current hazardous drinking was derived using the Alcohol Use Disorders Identification Test (AUDIT).

Results

An estimated 11.8% of Ontario adolescents (95% CI 10.1% to 13.8%) reported a history of former TBI and were not hazardous drinkers; 4.0% (95% CI 2.9% to 5.5%) reported recent TBI and were not hazardous drinkers; 13.7% (95% CI 12.3% to 15.3%) were hazardous drinkers who never had a TBI; 4.1% (95% CI 2.9% to 5.8%) had former TBI with co-occurring hazardous drinking; and 2.2% (95% CI 1.6% to 3.0%) had recent TBI with co-occurring hazardous drinking. Most odds increased significantly and were two to three times higher for reporting compromised mental health, violent and non-violent conduct behaviours, and reported victimisation for classifying as a hazardous drinker at the time of testing with co-occurring either former or recent TBI compared to classifying as not having either of these conditions. Adolescents classified as hazardous drinkers with former TBI had numerous and higher ORs for conduct behaviours than those with recent TBI.

Conclusions

Results emphasise the strong interplay between TBI and hazardous drinking and point to the need for integrating prevention efforts to reduce these conditions and their co-occurrence among adolescents.

Brick-tea type fluorosis is a public health concern in the north west area of China. The vitamin D receptor (VDR)-FokI polymorphism is considered to be a regulator of bone metabolism and calcium resorption. However, the association of VDR-FokI polymorphism with the risk of brick-tea type fluorosis has not been reported.

Materials and methods

A cross sectional, case control study was conducted in three provinces (Inner Mongolia, Qinghai and Sinkiang) in China. The fluoride content of Brick-tea water and urine was tested using the standards GB 1996–2005 and WS/T89-2006 (China), respectively. Skeletal fluorosis was diagnosed using the standard WS/192-2008 (China). The VDR-FokI polymorphism was detected by the Sequenom MassARRAY system.

Result

Compared with carriers of the CC genotype, participants with the CT/TT genotype had a significantly decreased risk of skeletal fluorosis (OR=0.761 (95% CI 0.580 to 0.997)), after adjustment for risk factors. When investigated among ethnic groups, the protective effect of the CT/TT genotype was limited in the Mongolian participants (OR=0.525 (95% CI 0.278 to 0.991)). Moreover, the interaction of VDR-FokI with risk factors was only found in Mongolian participants: the protective effect of the CT/TT genotype was limited to participants with >7.0 mg/day daily intake of tea fluoride (OR=0.085 (95% CI 0.009 to 0.851), participants with >3.2 mg/L urine fluoride (OR=0.103 (95% CI 0.017 to 0.633)) or participants aged 46–65 years (OR=0.404 (95% CI 0.177 to 0.922).

Conclusions

Our data suggest that the CT/TT genotype of VDR-FokI may be a protective factor for brick-tea type skeletal fluorosis, and this effect is pronounced in Mongolian participants.

To identify the combination of factors most protective of developmental delay at age 2 among children exposed to poor maternal mental health.

Design

Observational cohort study.

Setting

Pregnant women were recruited from primary healthcare offices, the public health laboratory service and community posters in Calgary, Alberta, Canada.

Participants

1596 mother–child dyads who participated in the All Our Babies study and who completed a follow-up questionnaire when their child was 2 years old. Among participants who completed the 2-year questionnaire and had complete mental health data (n=1146), 305 women (27%) were classified as high maternal mental health risk.

Primary measures

Child development at age 2 was described and a resilience analysis was performed among a subgroup of families at maternal mental health risk. The primary outcome was child development problems. Protective factors were identified among families at risk, defined as maternal mental health risk, a composite measure created from participants’ responses to mental health life course questions and standardised mental health measures.

Results

At age 2, 18% of children were classified as having development problems, 15% with behavioural problems and 13% with delayed social–emotional competencies. Among children living in a family with maternal mental health risk, protective factors against development problems included higher social support, higher optimism, more relationship happiness, less difficulty balancing work and family responsibilities, limiting the child's screen time to <1 hour per day and the child being able to fall asleep in <30 min and sleeping through the night by age 2.

Conclusions

Among families where the mother has poor mental health, public health and early intervention strategies that support interpersonal relationships, social support, optimism, work–life balance, limiting children's screen time and establishing good sleep habits in the child's first 2 years show promise to positively influence early child development.

This study aimed to determine the extent to which objectively measured sitting time at work is associated with the course of neck–shoulder pain across 1 year in blue-collar workers.

Methods

Data were analysed from 625 blue-collar workers in the Danish PHysical ACTivity cohort with Objective measurements (DPHACTO) cohort study (2012–2013). Objective data on sitting time were collected at baseline using accelerometry. Self-reported pain intensity (numeric rating scale 0–10) in the neck–shoulder region was registered for 1 year using repeated text messages (14 in total). Linear mixed models were used to determine the relationship between per cent time in sitting at work and trajectories of neck–shoulder pain, with and without adjustment for demographic, occupational and lifestyle factors, and baseline pain intensity.

Results

More sitting time at work was associated with a faster decline in pain intensity over 12 months, as indicated by a statistically significant effect of sitting on pain trajectories in the crude (p=0.020) and fully adjusted models (p=0.027).

Conclusions

In blue-collar workers, more sitting time at work was associated with a favourable development of pain intensity over time. The relationship between sitting at work and pain needs further investigation before explicit recommendations and guidelines on sedentary behaviour among blue-collar workers can be developed.

Transient ischaemic attacks (TIAs) are an important precursor of stroke. Atrial fibrillation (AF) is among the most dangerous aetiologies shared between TIAs and strokes. Detection of AF after TIAs is essential for the initiation of oral anticoagulants. We aimed to identify variations in the use of cardiac investigations used to detect AF and cardiac pathology in patients with TIA in the UK.

Setting

All TIA clinical leads in England and Wales received an invitation by email to participate in an online survey in February 2015. The questionnaire consisted of 36 multiple choice questions covering the domains: (1) general information about stroke units, (2) ECG diagnostics and cardiologic work-up and (3) management of AF.

Results

146 survey invitations were sent. The response rate was 40% (n=59). Diagnosis of AF largely depends on medical history and 12-channel ECG which is performed in the vast majority of patients with TIA (>75%) in 94.1% of the TIA services. Many patients with TIA either do not receive 24-hour Holter recording (requested regularly in 42% of the services) or only after considerable delay (>2 weeks). Prolonged event recording is only rarely performed (16%). Only about half of patients with TIA undergo echocardiography. Cranial imaging in patients with TIA is mainly performed as CT (62%). The majority of TIA clinics rapidly initiate anticoagulation in TIA patients with AF (81.6%) preferably using new oral anticoagulants (75.5%).

Conclusions

Significant variation in the cardiac diagnostic work-up following TIA exists regarding the use of particular detection techniques and the duration of cardiac ECG monitoring. Only limited resources are allocated to cardiac evaluation. In addition to research establishing the optimal ECG technique for patients with TIA, healthcare delivery programmes are needed to ensure proper management to prevent strokes.

To quantify and characterise missed opportunities for earlier HIV diagnosis in patients diagnosed with advanced HIV.

Design

A retrospective observational cohort study.

Setting

A central tertiary medical centre in Israel.

Measures

The proportion of patients with advanced HIV, the proportion of missed opportunities to diagnose them earlier, and the rate of clinical indicator diseases (CIDs) in those patients.

Results

Between 2010 and 2015, 356 patients were diagnosed with HIV, 118 (33.4%) were diagnosed late, 57 (16%) with advanced HIV disease. Old age (OR=1.45 (95% CI 1.16 to 1.74)) and being heterosexual (OR=2.65 (95% CI 1.21 to 5.78)) were significant risk factors for being diagnosed late. All patients with advanced disease had at least one CID that did not lead to an HIV test in the 5 years prior to AIDS diagnosis. The median time between CID and AIDS diagnosis was 24 months (IQR 10–30). 60% of CIDs were missed by a general practitioner and 40% by a specialist.

Conclusions

Missed opportunities to early diagnosis of HIV occur in primary and secondary care. Lack of national guidelines, lack of knowledge regarding CIDs and communication barriers with patients may contribute to a late diagnosis of HIV.

To investigate the feasibility of a full-scale randomised controlled trial of a picture booklet to improve quality of life for people with epilepsy and learning disabilities.

Trial design

A randomised controlled feasibility trial. Randomisation was not blinded and was conducted using a centralised secure database and a blocked 1:1 allocation ratio.

Setting

Epilepsy clinics in 1 English National Health Service (NHS) Trust.

Participants

Patients with learning disabilities and epilepsy who had: a seizure within the past 12 months, meaningful communication and a carer with sufficient proficiency in English.

Intervention

Participants in the intervention group used a picture booklet with a trained researcher, and a carer present. These participants kept the booklet, and were asked to use it at least twice more over 20 weeks. The control group received treatment as usual, and were provided with a booklet at the end of the study.

Outcome measures

7 feasibility criteria were used relating to recruitment, data collection, attrition, potential effect on epilepsy-related quality of life (Epilepsy and Learning Disabilities Quality of Life Scale, ELDQOL) at 4-week, 12-week and 20-week follow-ups, feasibility of methodology, acceptability of the intervention and potential to calculate cost-effectiveness.

Outcome

The recruitment rate of eligible patients was 34% and the target of 40 participants was reached. There was minimal missing data and attrition. An intention-to-treat analysis was performed; data from the outcome measures suggest a benefit from the intervention on the ELDQOL behaviour and mood subscales at 4 and 20 weeks follow-up. The booklet and study methods were positively received, and no adverse events were reported. There was a positive indication of the potential for a cost-effectiveness analysis.

Conclusions

All feasibility criteria were fully or partially met, therefore confirming feasibility of a definitive trial.

To seek community pharmacists' perception on use, safety and possible effectiveness of e-cigarettes as quit smoking tools, and their future regulation.

Setting

A survey of a sample of 154 community pharmacies across London, UK.

Context

E-cigarettes have exclusively established themselves in the market through consumers-led demand. To date, e-cigarettes still remain unregulated and can be easily purchased in shops, over the internet, but more controversially also in pharmacies in the UK. Pharmacists find themselves with a shortage of information on their safety and efficacy, and may experience an ethical dilemma when consulted by patients/customers.

Key findings

Response rate: 60% (n=92). Independent pharmacies accounted for 90% of the sample. The majority of participants (73%) sell e-cigarettes. A minority of participants (20%) have been presented with adverse effects such as cough and dry mouth. As possible reasons for their use, pharmacists ranked ‘aid in stop smoking’ as the most important (56%), with ‘cheaper alternative’ (43%) and ‘social/recreational use’ (31%) being the least important ones. Safety issues were raised as statements such as ‘e-liquid in cartridges may be toxic’ were agreed by 52% of respondents. The majority of pharmacists (97%) were supportive of e-cigarettes being regulated, expressing current concerns regarding excipients (42%) and nicotine content (34%). Participants indicated that they would require training in the form of information packs (88%), online tutorials (67%), continuous professional development (CPD) workshops (43%) to cover safety, counselling, dosage instructions, adverse effects and role in the smoking cessation care pathway in the future.

Conclusions

Pharmacists expressed concerns about the safety of e-cigarettes, especially regarding the amounts of excipients and nicotine as these still remain unregulated. Currently, there are no guidelines for pharmacists regarding e-cigarettes. Community pharmacists look forward to regulations so to conduct their duties in a more confident and legislated fashion.

To explore patient, caregiver and physician perceptions and attitudes regarding the balance of benefit and risk in using antibacterial drugs developed through streamlined development processes.

Design

Semistructured focus groups and in-depth interviews were conducted to elicit perceptions and attitudes about the use of antibacterial drugs to treat multidrug-resistant infections. Participants were given background information about antibiotic resistance, streamlined drug development programmes and FDA drug approval processes. Audio recordings of focus groups/interviews were reviewed and quotes excerpted and categorised to identify key themes.

Participants

Two primary stakeholder groups were engaged: one comprising caregivers, healthy persons and patients who had recovered from or were at risk of resistant infection (N=67; 11 focus groups); and one comprising physicians who treat resistant infections (N=23).

Results

Responses from focus groups/interviews indicated widespread awareness among patients/caregivers and physicians of the seriousness of the problem of antibacterial resistance. Both groups were willing to accept a degree of uncertainty regarding the balance of risk and benefit in a new therapy where a serious unmet need exists, but also expressed a desire for rigorous monitoring and rapid, transparent reporting of safety/effectiveness data. Both groups wanted to ensure that >1 physician had input on whether to treat patients with antibiotics developed through a streamlined process. Some patients/caregivers unfamiliar with exigencies of critical care suggested a relatively large multidisciplinary team, while physicians believed individual expert consultations would be preferable. Both groups agreed that careful oversight and stewardship of antibacterial drugs are needed to ensure patient safety, preserve efficacy and prevent abuse.

Conclusions

Groups comprising patients/caregivers and physicians were aware of serious issues posed by resistant infections and the lack of effective antibacterial drug therapies and shared a consensus that streamlined development programmes represent a necessary response to the resistance crisis, but one that requires enhanced safeguards and risk communication.

To live with heart failure means that life is delimited. Still, people with heart failure can have a desire to stay active in working life as long as possible. Although a number of factors affect sick leave and rehabilitation processes, little is known about sick leave and vocational rehabilitation concerning people with heart failure. This study aimed to identify emotions and encounters with healthcare professionals as possible predictors for the self-estimated ability to return to work in people on sick leave due to heart failure.

Design

A population-based cross-sectional study design was used.

Setting

The study was conducted in Sweden. Data were collected in 2012 from 3 different sources: 2 official registries and 1 postal questionnaire.

3 variables, feeling strengthened in the situation (β=–0.21, p=0.02), feeling happy (β=–0.24, p=0.02) and receiving encouragement about work (β=–0.32, p≤0.001), were identified as possible predictive factors for the self-estimated ability to return to work.

Conclusions

To feel strengthened, happy and to receive encouragement about work can affect the return to work process for people on sick leave due to heart failure. In order to develop and implement rehabilitation programmes to meet these needs, more research is needed.

The use of retail purchasing data may improve adherence prediction over approaches using healthcare insurance claims alone.

Design

Retrospective.

Setting and participants

A cohort of patients who received prescription medication benefits through CVS Caremark, used a CVS Pharmacy ExtraCare Health Care (ECHC) loyalty card, and initiated a statin medication in 2011.

Outcome

We evaluated associations between retail purchasing patterns and optimal adherence to statins in the 12 subsequent months.

Results

Among 11 010 statin initiators, 43% were optimally adherent at 12 months of follow-up. Greater numbers of store visits per month and dollar amount per visit were positively associated with optimal adherence, as was making a purchase on the same day as filling a prescription (p<0.0001 for all). Models to predict adherence using retail purchase variables had low discriminative ability (C-statistic: 0.563), while models with both clinical and retail purchase variables achieved a C-statistic of 0.617.

Conclusions

While the use of retail purchases may improve the discriminative ability of claims-based approaches, these data alone appear inadequate for adherence prediction, even with the addition of more complex analytical approaches. Nevertheless, associations between retail purchasing behaviours and adherence could inform the development of quality improvement interventions.

We examined the relationships between screen time (ST) and mental health problems and also increment of ST and progression of mental health problems in a college-based sample of Chinese youth.

Methods

We assessed 2521 Chinese college freshmen from October 2013 to December 2014. At baseline, the mean age of participants was 18.43 years (SD 0.96 years), and 1215 (48.2%) participants reported ST >2 h/day. We estimated multivariable-adjusted ORs by using logistic regression models for the risk of developing mental health problems (anxiety, depression and psychopathological symptoms) and/or progression of these problems, according to baseline ST exposure and changes in exposure at follow-up.

Results

At baseline, when ST >2 h/day was compared with ST ≤2 h/day, the OR was 1.38 (95% CI 1.15 to 1.65) for anxiety, 1.55 (95% CI 1.25 to 1.93) for depression and 1.49 (95% CI 1.22 to 1.83) for psychopathological symptoms. The results remained unchanged for depressive and psychopathological symptoms but not for anxiety, after additional adjustment for sex, age, residential background, body mass index, perceived family economy, sleep quality, smoking, alcohol intake, exercise after school and physical activity. When participants who had increased their ST exposure to >2 h/day were compared with those with no change and ST ≤2 h/day, the OR was 1.78 (95% CI 1.12 to 2.83) for anxiety, 1.92 (95% CI 1.23 to 2.83) for depression and 1.93 (95% CI 1.16 to 3.21) for psychopathological symptoms. These associations also remained after additional adjustment.

Conclusions

The overall effects are consistent yet small for ST/ST increment on mental health problems and its progression. Given the small effect size of the current results, it remains unclear the degree to which ST is a practically significant risk factor for mental health outcomes. Future studies of high quality are necessary to further examine this association and the direction of causality.

While national quality registries (NQRs) are suggested to provide opportunities for systematic follow-up and learning opportunities, and thus clinical improvements, features in registries and contexts triggering such processes are not fully known. This study focuses on one of the world's largest stroke registries, the Swedish NQR Riksstroke, investigating what aspects of the registry and healthcare organisations facilitate or hinder the use of registry data in clinical quality improvement.

Methods

Following particular qualitative studies, we performed a quantitative survey in an exploratory sequential design. The survey, including 50 items on context, processes and the registry, was sent to managers, physicians and nurses engaged in Riksstroke in all 72 Swedish stroke units. Altogether, 242 individuals were presented with the survey; 163 responded, representing all but two units. Data were analysed descriptively and through multiple linear regression.

Results

A majority (88%) considered Riksstroke data to facilitate detection of stroke care improvement needs and acknowledged that their data motivated quality improvements (78%). The use of Riksstroke for quality improvement initiatives was associated (R2=0.76) with ‘Colleagues’ call for local results’ (p=<0.001), ‘Management Request of Registry data’ (p=<0.001), and it was said to be ‘Simple to explain the results to colleagues’ (p=0.02). Using stepwise regression, ‘Colleagues’ call for local results’ was identified as the most influential factor. Yet, while 73% reported that managers request registry data, only 39% reported that their colleagues call for the unit's Riksstroke results.

Conclusions

While an NQR like Riksstroke demonstrates improvement needs and motivates stakeholders to make progress, local stroke care staff and managers need to engage to keep the momentum going in terms of applying registry data when planning, performing and evaluating quality initiatives.

There is a lack of high-quality evidence for physiotherapy post lumbar discectomy. Substantial heterogeneity in treatment effects may be explained by variation in quality, administration and components of interventions. An optimised physiotherapy intervention may reduce heterogeneity and improve patient benefit. The objective was to describe, analyse and evaluate an optimised 1:1 physiotherapy outpatient intervention for patients following primary lumbar discectomy, to provide preliminary insights.

Design

A descriptive analysis of the intervention embedded within an external pilot and feasibility trial.

To report the nationwide prevalence of facial palsy (FP) of grade III or worse in the House–Brackmann (H–B) grading system in South Korea and assess the associated factors.

Design

Cross-sectional analysis of a nationwide health survey.

Settings

South Korea.

Methods

We obtained data from the 2010 to 2012 Korea National Health and Nutrition Examination Surveys, which were cross-sectional surveys of the South Korean civilian population living in households and aged ≥1 year (N=23 533). A field survey team performed interviews, physical examinations and laboratory tests. Facial expression was evaluated based on the H–B grading system.

Results

Among the population aged ≥1 year, the prevalence of FP of grade III or worse in the H–B grading system was 0.12% (95% CI 0.07% to 0.17%). FP was more prevalent in women (p=0.01) and the prevalence rate increased with age (p<0.001). In participants aged ≥19 years, age, female gender, history of cardiovascular disease and the serum total cholesterol level were associated with FP in a multivariable analysis. In the evaluation of lifestyle, the individuals with FP had a higher rate of depressive mood and were more restricted in their daily activities.

Conclusions

Considering the significance of facial expression in psychosocial activities, public acknowledgement and further intervention are required to support patients with this distressing condition.

Early diagnosis and treatment of heterozygous familial hypercholesterolaemia (HeFH) is known to be associated with reduced mortality from premature coronary artery disease, but HeFH remains underdiagnosed. This survey aims to determine knowledge and current management of HeFH in general practice.

Setting

An online questionnaire was administered to general practitioners’ (GPs’) in the North West of England to assess their knowledge and management of HeFH.

Participants

Practising GPs in the North West of England were contacted by email and invited to complete an online questionnaire. Recruitment discontinued when the target of 100 was reached.

Primary outcome

An assessment of the knowledge and current management of HeFH in GPs.

Results

100 GP responses were analysed. Although only 39% considered themselves to have reasonable knowledge of HeFH, 89% knew that HeFH was a genetic disorder and 74% selected the correct lipid profile for diagnosing the condition. More than half (61%) were aware of current guidelines on HeFH. Gaps in knowledge were evident when only 30% correctly identified the prevalence of HeFH and half were not aware of the pattern of inheritance. Increased cardiovascular risk was underestimated by majority. 33% thought that they had HeFH patients in their practice confirming underdiagnosis of the condition. Statin therapy was recognised by 94% to be the right medication for treating HeFH. The majority (82%) regarded GPs to be the most effective healthcare professional for early recognition of HeFH.

Conclusions

GPs have an above-average knowledge of familial hypercholesterolaemia (FH) and almost universally consider that they have a key role in the early recognition of undiagnosed HeFH patients in the community. However, there are gaps in awareness that need to be addressed to further enhance the care of FH in the community.

Healthcare costs and usage are rising. Evidence-based online health information may reduce healthcare usage, but the evidence is scarce. The objective of this study was to determine whether the release of a nationwide evidence-based health website was associated with a reduction in healthcare usage.

Design

Interrupted time series analysis of observational primary care data of healthcare use in the Netherlands from 2009 to 2014.

Setting

General community primary care.

Population

912 000 patients who visited their general practitioners 18.1 million times during the study period.

Intervention

In March 2012, an evidence-based health information website was launched by the Dutch College of General Practitioners. It was easily accessible and understandable using plain language. At the end of the study period, the website had 2.9 million unique page views per month.

Main outcomes measures

Primary outcome was the change in consultation rate (consultations/1000 patients/month) before and after the release of the website. Additionally, a reference group was created by including consultations about topics not being viewed at the website. Subgroup analyses were performed for type of consultations, sex, age and socioeconomic status.

Results

After launch of the website, the trend in consultation rate decreased with 1.620 consultations/1000 patients/month (p<0.001). This corresponds to a 12% decline in consultations 2 years after launch of the website. The trend in consultation rate of the reference group showed no change. The subgroup analyses showed a specific decline for consultations by phone and were significant for all other subgroups, except for the youngest age group.

Conclusions

Healthcare usage decreased by 12% after providing high-quality evidence-based online health information. These findings show that e-Health can be effective to improve self-management and reduce healthcare usage in times of increasing healthcare costs.

To estimate the prevalence of, and explore potential risk factors for, taste and smell dysfunction in the general population of the USA.

Design

A cross-sectional study.

Setting

A cross-sectional analysis of data collected in the National Health and Nutrition Examination Survey (NHANES 2013–2014).

Participants

A total of 3519 men and women aged 40 years and older who participated in NHANES 2013–2014.

Main outcome measures

Using the NHANES Pocket Smell Test, smell impairment was defined as failing to correctly identify 6 or more of the 8 odours. Taste impairment was defined as failing to correctly identify quinine or sodium chloride.

Results

The estimated prevalence was 13.5% for smell impairment, 17.3% for taste impairment and 2.2% for taste and smell impairment. For smell, but not taste, prevalence estimates increased with age and were higher in men and ethnic minorities. In backward stepwise logistic regression, low educational attainment, low family income and a history of asthma or cancer were independently associated with a higher prevalence of smell impairment, whereas light-to-moderate alcohol consumption (1–3 drinks/day) was associated with a lower prevalence of this condition. After multivariate adjustment, being non-Hispanic Black Americans, consuming ≥4 drinks of alcohol per day and having a history of cardiovascular disease (CVD) were independently associated with a higher prevalence of taste impairment.

Conclusions

Based on a nationally representative multistage probability survey among the US population aged 40 years and older, smell and taste dysfunction affected ~20.5 million (13.5%) and 26.3 million (17.3%) individuals, respectively. Age, gender, ethnicity, educational attainment, family income, light-to-moderate alcohol consumption and history of asthma or cancer were significant risk factors for smell dysfunction, whereas only ethnicity, heavy alcohol consumption and CVD history were associated with a higher prevalence of taste dysfunction.

The UK ambulance service is expected to now manage more patients in the community and avoid unnecessary transportations to hospital emergency departments (ED). Most people it attends who have experienced seizures have established epilepsy, have experienced uncomplicated seizures and so do not require the full facilities of an ED. Despite this, most are transported there. To understand why, we explored paramedics’ experiences of managing seizures.

Design and setting

Semistructured interviews were conducted with a purposive sample of paramedics from the English ambulance service. Interviews were transcribed and thematically analysed.

Participants

A diverse sample of 19 professionals was recruited from 5 different ambulance NHS trusts and the College of Paramedics.

Results

Participants’ confirmed how most seizure patients attended to do not clinically require an ED. They explained, however, that a number of factors influence their care decisions and create a momentum for these patients to still be taken. Of particular importance was the lack of access paramedics have to background medical information on patients. This, and the limited seizure training paramedics receive, meant paramedics often cannot interpret with confidence the normality of a seizure presentation and so transport patients out of precaution. The restricted time paramedics are expected to spend ‘on scene’ due to the way the ambulance services’ performance is measured and that are few alternative care pathways which can be used for seizure patients also made conveyance likely.

Conclusions

Paramedics are working within a system that does not currently facilitate non-conveyance of seizure patients. Organisational, structural, professional and educational factors impact care decisions and means transportation to ED remains the default option. Improving paramedics access to medical histories, their seizure management training and developing performance measures for the service that incentivise care that is cost-effective for all of the health service might reduce unnecessary conveyances to ED.

To systematically review how process evaluations are currently designed, what methodologies are used and how are they developed alongside or within neurological rehabilitation trials.

Methods

This mixed-methods systematic review had two evidence streams: stream I, studies reporting process evaluations alongside neurorehabilitation trials research and stream II, methodological guidance on process evaluation design and methodology. A search strategy was designed for each evidence stream. Data regarding process evaluation core concepts and design issues were extracted using a bespoke template. Evidence from both streams was analysed separately and then synthesised in a final overarching synthesis proposing a number of recommendations for future research.

Results

A total of 124 process evaluation studies, reporting on 106 interventions, were included in stream I evidence. 30 studies were included as stream II evidence. Synthesis 1 produced 9 themes, and synthesis 2 identified a total of 8 recommendations for process evaluation research. The overall synthesis resulted in 57 ‘synthesis recommendations’ about process evaluation methodology grouped into 9 research areas, including the use of theory, the investigation of context, intervention staff characteristics and the delivery of the trial intervention.

Conclusions

There remains no consensus regarding process evaluation terminology within the neurological rehabilitation field. There is a need for process evaluations to address the nature and influence of context over time. Process evaluations should clearly describe what intervention staff bring to a trial, including skills and experience prior to joining the research. Process evaluations should monitor intervention staff's learning effects and the possible impact that these may have on trial outcomes.

Many reports exist of the cardiovascular toxicity of smoked cannabis but none of arterial stiffness measures or vascular age (VA). In view of its diverse toxicology, the possibility that cannabis-exposed patients may be ageing more quickly requires investigation.

Differences between group chronological ages (CA, 30.47±0.48 to 40.36±2.44, mean±SEM) were controlled with linear regression. Between-group sex differences were controlled by single-sex analysis. Mean cannabis exposure among patients was 37.67±7.16 g-years. In regression models controlling for CA, Body Mass Index (BMI), time and inhalant group, the effect of cannabis use on VA was significant in males (p=0.0156) and females (p=0.0084). The effect size in males was 11.84%. A dose–response relationship was demonstrated with lifetime exposure (p<0.002) additional to that of tobacco and opioids. In both sexes, the effect of cannabis was robust to adjustment and was unrelated to its acute effects. Significant power interactions between cannabis exposure and the square and cube of CA were demonstrated (from p<0.002).

Conclusions

Cannabis is an interactive cardiovascular risk factor (additional to tobacco and opioids), shows a prominent dose–response effect and is robust to adjustment. Cannabis use is associated with an acceleration of the cardiovascular age, which is a powerful surrogate for the organismal–biological age. This likely underlies and bi-directionally interacts with its diverse toxicological profile and is of considerable public health and regulatory importance.

Communication technologies, such as personal online health communities, are increasingly considered as a tool to realise patient empowerment. However, little is known about the actual use of online health communities. Here, we investigated if and how patients' use of online communities supports patient empowerment.

Setting

A network of primary and secondary care providers around individual patients with Parkinson's disease.

Participants

We conducted case studies to examine our research question. We interviewed 18 patients with Parkinson's disease and observed the use of online health communities of 14 of them for an average of 1 year.

Primary outcome measures

We analysed the interviews and the online conversations between patients and healthcare providers, using Foucault's framework for studying power processes.

Results

We observed that patient empowerment is inhibited by implicit norms that exist within these communities around the number and content of postings. First, patients refrained from asking too many questions of their healthcare providers, but felt obliged to offer them regular updates. Second, patients scrutinised the content of their postings, being afraid to come across as complainers. Third, patients were cautious in making knowledge claims about their disease.

Conclusions

Changing implicit norms within online communities and the societal context they exist in seems necessary to achieve greater patient empowerment. Possibilities for changing these norms might lie in open dialogue between patient and healthcare providers about expectations, revising the curriculum of medical education and redesigning personal online health communities to support two-way knowledge exchange.

Rates of out-of-hospital cardiac arrest (OHCA) and bystander cardiopulmonary resuscitation (CPR) have been shown to vary considerably in Victoria. We examined the extent to which this variation could be explained by the sociodemographic and population health characteristics of the region.

Methods

Using the Victorian Ambulance Cardiac Arrest Registry, we extracted OHCA cases occurring between 2011 and 2013. We restricted the calculation of bystander CPR rates to those arrests that were witnessed by a bystander. To estimate the level of variation between Victorian local government areas (LGAs), we used a two-stage modelling approach using random-effects modelling.

Results

Between 2011 and 2013, there were 15 830 adult OHCA in Victoria. Incidence rates varied across the state between 41.9 to 104.0 cases/100 000 population. The proportion of the population over 65, socioeconomic status, smoking prevalence and education level were significant predictors of incidence in the multivariable model, explaining 93.9% of the variation in incidence among LGAs. Estimates of bystander CPR rates for bystander witnessed arrests varied from 62.7% to 73.2%. Only population density was a significant predictor of rates in a multivariable model, explaining 73% of the variation in the odds of receiving bystander CPR among LGAs.

Conclusions

Our results show that the regional characteristics which underlie the variation seen in rates of bystander CPR may be region specific and may require study in smaller areas. However, characteristics associated with high incidence and low bystander CPR rates can be identified and will help to target regions and inform local interventions to increase bystander CPR rates.

Parents are often children's main source of support following fear-inducing traumatic events, yet little is known about how parents provide that support. The aim of this study was to examine parents' experiences of supporting their child following child trauma exposure and presentation at an emergency department (ED).

The setting for this study was two National Health Service EDs in England.

Participants

20 parents whose child experienced a traumatic event and attended an ED between August 2014 and October 2015.

Results

Parents were sensitive to their child's distress and offered reassurance and support for their child to resume normal activities. However, parental beliefs often inhibited children's reinstatement of pretrauma routines. Support often focused on preventing future illness or injury, reflective of parents' concerns for their child's physical well-being. In a minority of parents, appraisals of problematic care from EDs contributed to parents' anxiety and perceptions of their child as vulnerable post-trauma. Forgetting the trauma and avoidance of discussion were encouraged as coping strategies to prevent further distress. Parents highlighted their need for further guidance and support regarding their child's physical and emotional recovery.

Conclusions

This study provides insight into the experiences of and challenges faced by parents in supporting their child following trauma exposure. Perceptions of their child's physical vulnerability and treatment influenced parents' responses and the supportive strategies employed. These findings may enable clinicians to generate meaningful advice for parents following child attendance at EDs post-trauma.

The purpose of this study is (1) to identify obesity-related lifestyle behaviour patterns of diet, physical activity, sedentary and sleep behaviours in preschool children, (2) to examine the association between identified behaviour clusters and overweight/obesity and (3) to investigate differences in children's family environments according to clusters.

Design setting and participants

A cross-sectional study on 2114 preschool children aged 3–6 years who attended childcare facilities (24 nursery schools and 10 kindergartens) in Tsuruoka city, Japan in April 2003 was conducted.

Main outcome measures

Children's principal caregivers completed a questionnaire on children's lifestyle behaviours (dinner timing, outside playtime, screen time and night-time sleep duration), family environment (family members, maternal employment, mealtime regularity and parents' habitual exercise and screen time) and measurements of weight and height. Cluster analysis was performed using children's 4 lifestyle behaviours based on those non-missing values (n=1545). The 2 tests and analysis of variance (ANOVA) estimated cluster differences in overweight/obesity and family environments.

Results

6 clusters were identified. Children's overweight/obesity varied across clusters (p=0.007). The cluster with the most screen time, shorter night-time sleep duration, average dinner timing and outside playtime had the highest overweight/obesity prevalence (15.1%), while the cluster with the least screen time, the longest sleep duration, the earliest dinner timing and average outside playtime had the lowest prevalence (4.0%). Family environments regarding mealtime regularity and both parents' screen time also significantly varied across clusters. The cluster having the highest overweight/obesity prevalence had the highest proportion of irregular mealtimes and the most screen time for both parents.

Conclusions

This study suggests that public health approaches to prevent children's overweight/obesity should focus on decreasing screen time and increasing night-time sleep duration. To shape those behaviours, regular mealtimes and decreasing parents' screen time within family environments need to be targeted among family members.

To determine the diagnostic accuracy of different methods of blood pressure (BP) measurement compared with reference standards for the diagnosis of hypertension in patients with obesity with a large arm circumference.

4037 potentially relevant papers were identified. 20 studies involving 26 different comparisons met the inclusion criteria. Individual patient data were available from 4 studies. No studies satisfied all QUADAS2 criteria. Compared with the reference test of invasive BP, a correctly fitting upper arm BP cuff had a sensitivity of 0.87 (0.79 to 0.93) and a specificity of 0.85 (0.64 to 0.95); insufficient evidence was available for other comparisons to invasive BP. Compared with the reference test of a correctly fitting upper arm cuff, BP measurement at the wrist had a sensitivity of 0.92 (0.64 to 0.99) and a specificity of 0.92 (0.85 to 0.87). Measurement with an incorrectly fitting standard cuff had a sensitivity of 0.73 (0.67 to 0.78) and a specificity of 0.76 (0.69 to 0.82). Measurement at the forearm had a sensitivity of 0.84 (0.71 to 0.92) and a specificity 0.75 of (0.66 to 0.83). Bland-Altman analysis of individual patient data from 3 studies comparing wrist and upper arm BP showed a mean difference of 0.46 mm Hg for systolic BP measurement and 2.2 mm Hg for diastolic BP measurement.

Conclusions

BP measurement with a correctly fitting upper arm cuff is sufficiently sensitive and specific to diagnose hypertension in patients with obesity with a large upper arm circumference. If a correctly fitting upper arm cuff cannot be applied, an incorrectly fitting standard size cuff should not be used and BP measurement at the wrist should be considered.

The National Health Service England, Commissioning for Quality and Innovation for Antimicrobial Resistance (CQUIN AMR) aims to reduce the total antibiotic consumption and the use of certain broad-spectrum antibiotics in secondary care. However, robust baseline antibiotic use data are lacking for hospitalised children. In this study, we aim to describe, compare and explain the prescription patterns of antibiotics within and between paediatric units in the UK and to provide a baseline for antibiotic prescribing for future improvement using CQUIN AMR guidance.

Methods

We conducted a cross-sectional study using a point prevalence survey (PPS) in 61 paediatric units across the UK. The standardised study protocol from the Antibiotic Resistance and Prescribing in European Children (ARPEC) project was used. All inpatients under 18 years of age present in the participating hospital on the day of the study were included except neonates.

Results

A total of 1247 (40.9%) of 3047 children hospitalised on the day of the PPS were on antibiotics. The proportion of children receiving antibiotics showed a wide variation between both district general and tertiary hospitals, with 36.4% ( 95% CI 33.4% to 39.4%) and 43.0% (95% CI 40.9% to 45.1%) of children prescribed antibiotics, respectively. About a quarter of children on antibiotic therapy received either a medical or surgical prophylaxis with parenteral administration being the main prescribed route for antibiotics (>60% of the prescriptions for both types of hospitals). General paediatrics units were surprisingly high prescribers of critical broad-spectrum antibiotics, that is, carbapenems and piperacillin-tazobactam.

Conclusions

We provide a robust baseline for antibiotic prescribing in hospitalised children in relation to current national stewardship efforts in the UK. Repeated PPS with further linkage to resistance data needs to be part of the antibiotic stewardship strategy to tackle the issue of suboptimal antibiotic use in hospitalised children.

The relationship between obesity and type 2 diabetes mellitus (T2DM) varies with geographical area and race.

Objectives

To investigate the prevalence of T2DM and the proportion of subjects with undiagnosed T2DM. In addition, to compare the associations between different obesity indices and T2DM for middle-aged and elderly people from six communities in Jinan, China.

Setting

A cross-sectional study was designed and the study subjects were chosen from blocks which were randomly selected in the 6 communities of Jinan, China in 2011–2012.

Participants

A total of 3277 residents aged ≥50 years were eligible for this study, but 1563 people were excluded because they did not provide anthropometric data such as height, weight, waist circumference (WC), hip circumference, systolic blood pressure, diastolic blood pressure, fasting plasma glucose, triglyceride (TG), total cholesterol (TC) or information about their current medication use. Hence, 1714 participants were included in the final data analysis.

Results

The prevalence of T2DM among people aged ≥50 years was 16.6% (19.3% for men and 15.3% for women) and the proportion of patients with undiagnosed T2DM was 32.7%. Compared with the lowest levels of body mass index (BMI), WC, waist-to-hip ratio or waist-to-stature ratio (WSR), the ORs and 95% CIs of the highest levels for men, after adjusting for age, smoking, alcohol drinking, regular exercise, hypertension, TG and TC, were 1.607 (0.804 to 3.210), 2.189 (1.118 to 4.285), 1.873 (0.968 to 3.623) and 2.572 (1.301 to 5.083), respectively, and for women, 2.764 (1.622 to 4.712), 2.407 (1.455 to 3.985), 2.500 (1.484 to 4.211) and 2.452 (1.447 to 4.155), respectively.

Conclusions

Among adults aged ≥50 years in Jinan, China, the best indicator of the relationship between obesity and T2DM is WSR for men and BMI for women, respectively.

Previous studies have reported that elderly victims of natural disasters might be prone to a subsequent decline in motor function. Victims of the Great East Japan Earthquake (GEJE) relocated to a wide range of different types of housing. As the evacuee lifestyle varies according to the type of housing available to them, their degree of motor function loss might also vary accordingly. However, the association between postdisaster housing type and loss of motor function has never been investigated. The present study was conducted to investigate the association between housing type after the GEJE and loss of motor function in elderly victims.

Methods

We conducted a prospective observational study of 478 Japanese individuals aged ≥65 years living in Miyagi Prefecture, one of the areas most significantly affected by the GEJE. Information on housing type after the GEJE, motor function as assessed by the Kihon checklist and other lifestyle factors was collected by interview and questionnaire in 2012. Information on motor function was then collected 1 year later. The multiple logistic regression model was used to estimate the multivariate adjusted ORs of motor function loss.

Results

We classified 53 (11.1%) of the respondents as having loss of motor function. The multivariate adjusted OR (with 95% CI) for loss of motor function among participants who were living in privately rented temporary housing/rental housing was 2.62 (1.10 to 6.24) compared to those who had remained in the same housing as that before the GEJE, and this increase was statistically significant.

Conclusions

The proportion of individuals with loss of motor function was higher among persons who had relocated to privately rented temporary housing/rental housing after the GEJE. This result may reflect the influence of a move to a living environment where few acquaintances are located (lack of social capital).

The risk of ischaemic heart disease (IHD) is largely influenced by lifestyle. Interestingly, cohort studies show that anxiety in general is associated with increased risk of IHD, independent of established risk factors for cardiovascular disease. Health anxiety is a specific type of anxiety characterised by preoccupation of having, acquiring or possibly avoiding illness, yet little is known about lifestyle and risk of disease development in this group.

Aim

Investigate whether health anxiety is prospectively associated with IHD, and whether a potential association can be explained by the presence or absence of established risk factors for cardiovascular diseases.

Methods

Incident IHD was studied among 7052 participants in the community-based Hordaland Health Study (HUSK) during 12 years follow-up by linkage to the Cardiovascular Diseases in Norway (CVDNOR) project. Scores above 90th centile of the Whiteley Index defined health anxiety cases. Associations were examined with the Cox proportional regression models.

Results

During follow-up, 6.1% of health anxiety cases developed IHD compared with 3.0% of non-cases, yielding a gender-adjusted HR of 2.12 (95% CI 1.52 to 2.95). After adjustments for established cardiovascular risk factors, about 70% increased risk of IHD was found among cases with health anxiety (HR: 1.73 (95% CI 1.21 to 2.48)). The association followed a dose–response pattern.

Conclusions

This finding corroborates and extends the understanding of anxiety in various forms as a risk factor for IHD. New evidence of negative consequences over time underlines the importance of proper diagnosis and treatment for health anxiety.

Laparoscopy is increasingly being used as an alternative to open surgery in the treatment of patients with colon cancer. The study objective is to estimate the difference in hospital costs between laparoscopic and open colon cancer surgery.

Design

Population-based retrospective cohort study.

Settings

All acute hospitals of the National Health System in England.

Population

A total of 55 358 patients aged 30 and over with a primary diagnosis of colon cancer admitted for planned (elective) open or laparoscopic major resection between April 2006 and March 2013.

Primary outcomes

Inpatient hospital costs during index admission and after 30 and 90 days following the index admission.

Results

Propensity score matching was used to create comparable exposed and control groups. The hospital cost of an index admission was estimated to be £1933 (95% CI 1834 to 2027; p<0.01) lower among patients who underwent laparoscopic resection. After including the first unplanned readmission following index admission, laparoscopy was £2107 (95% CI 2000 to 2215; p<0.01) less expensive at 30 days and £2202 (95% CI 2092 to 2316; p<0.01) less expensive at 90 days. The difference in cost was explained by shorter hospital stay and lower readmission rates in patients undergoing minimal access surgery. The use of laparoscopic colon cancer surgery increased 4-fold between 2006 and 2012 resulting in a total cost saving in excess of £29.3 million for the National Health Service (NHS).

Conclusions

Laparoscopy is associated with lower hospital costs than open surgery in elective patients with colon cancer suitable for both interventions.

The psychological effects of acute pulmonary embolism (PE) have scarcely been studied. The aims of this study were to evaluate health-related quality of life (HRQoL) in patients with a history of PE compared with that of the general population and buddy controls, and to explore factors that may predict impaired HRQoL.

Design

Cross-sectional.

Setting

Haematology and thrombosis unit in Fredrikstad, Norway.

Participants

213 consecutive patients treated for PE were identified from hospital registries. Eligible patients were scheduled for a single study visit, including a functional capacity test (6 min walking test). HRQoL was assessed using the EuroQol 5D dimensions 3-level (EQ-5D-3L) questionnaire, of which the results were compared with Danish population norms and age-matched and sex-matched buddy controls. The buddy controls were recruited by asking every patient to hand over the EQ-5D questionnaire to 2 age-matched and sex-matched friends or relatives. Multivariable regression analyses were used to examine possible determinants of reduced HRQoL.

Results

Mean age was 61 years (SD 15), 117 (55%) were males, and median time since diagnosis was 3.8 years (range 0.3–9.5). Mean EuroQol visual analogue scale (EQ VAS) was 67 in PE as compared with 81 in the general population (p<0.005) and corresponding EQ-5D index values were 0.80 and 0.86 (p<0.005). Patients reported more problems in all 5 EQ-5D compared with both the buddy controls and the general population, p<0.05. Shorter 6 min walking distance (β=0.09, p<0.005) and patient-reported dyspnoea (β=11.27, p<0.005) were independent predictors of lower EQ VAS scores.

Conclusions

Our findings show that patients with a history of PE have impaired HRQoL when compared with the general population and buddy controls. Reduced functional capacity and persistent dyspnoea were the main predictors of this impairment.

The objective of this study was to assess the effects of long-term offshore work on cerebral oxygenation oscillations in sailors based on the wavelet phase coherence (WPCO) of near-infrared spectroscopy (NIRS) signals.

Methods

The fatigue severity scale (FSS) was first applied to assess the fatigue level of sailors and age-matched controls. Continuous recordings of NIRS signals were then obtained from the prefrontal lobes in 30 healthy sailors and 30 age-matched controls during the resting state. WPCO between the left and right prefrontal oscillations was analysed and Pearson correlation analysis was used to study the relationship between the FSS and the wavelet amplitude (WA), and between the FSS and the WPCO level.

Results

The periodic oscillations of Delta (HbO2) signals were identified at six frequency intervals: I (0.6–2 Hz); II (0.145–0.6 Hz); III (0.052–0.145 Hz); IV (0.021–0.052 Hz); V (0.0095–0.021 Hz); and VI (0.005–0.0095 Hz). The WA in intervals I (F=8.823, p=0.004) and III (F=4.729, p=0.034) was significantly lower in sailors than that in the controls. The WPCO values of sailor group were significantly lower in intervals III (F=4.686, p=0.039), IV (F=4.864, p=0.036) and V (F=5.195, p=0.03) than those of the control group. In the sailor group, the WA in interval I (r=–0.799, p<0.01) and in interval III (r=–0.721, p<0.01) exhibited a negative correlation with the FSS. Also, the WPCO exhibited a negative correlation with the FSS in intervals III (r=–0.839, p<0.01), IV (r=–0.765, p<0.01) and V (r=–0.775, p<0.01) in the sailor group.

Conclusions

The negative correlation between WA and FSS indicates that the lower oscillatory activities might contribute to the development of fatigue. The low WPCO in intervals III, IV and V represents a reduced phase synchronisation of myogenic, neurogenic and endothelial metabolic activities respectively and this may suggest a decline of cognitive function.

A qualitative study of recalled experiences of early adolescent overweight/obesity revealed low levels of weight-related concern. This further analysis aimed to explore weight-related concern and weight-loss efforts as participants transitioned into adulthood.

Design, participants and methods

Participants were 35 young adults from a population-based cohort study who had body mass index (BMI) >95th centile between ages 11 and 15 and participated in semistructured interviews aged 24. At age 24, they were categorised as: ‘slimmers’ (N=13) who had lower BMI Z-scores at 24 than their adolescent peak and were not obese (BMI<30 kg/m2); ‘relapsers’ (N=8, of whom 2 were morbidly obese (BMI>35 kg/m2) at age 24); ‘stable’ (N=3, of whom 1 morbidly obese); and ‘gainers’ (N=11, of whom 5 morbidly obese). Themes were identified and coded using NVivo qualitative data analysis software, blind to participants’ current weight status.

Results

Contrasting with the lack of concern recalled in respect of earlier adolescence, weight-related concerns and/or desire to lose weight generally increased around the time of school leaving and almost all participants described some form of exercise (formal/informal) and dietary weight-control strategies. Among ‘slimmers’, there was some (subtle) evidence of more consistent use of exercise, self-monitoring of diet and exercise and of lifestyle changes becoming habitual and/or part of identity. Few participants had accessed professional support. Diet clubs seemed to have been used most by ‘gainers’, some only recently. Labour-market and housing transitions were strong influences, described as facilitating weight losses by some, but increases by others. For some participants, it appeared that weight loss was simply a by-product of these transitions.

Conclusions

In contrast to earlier adolescence, even the heaviest participants tended to show actual weight loss action or preparation for action. The transition to adulthood could thus be a key life stage for interventions.

This is a pilot study to investigate the type and severity of emotional distress in women after early pregnancy loss (EPL), compared with a control group with ongoing pregnancies. The secondary aim was to assess whether miscarriage or ectopic pregnancy impacted differently on the type and severity of psychological morbidity.

Design

This was a prospective survey study. Consecutive women were recruited between January 2012 and July 2013. We emailed women a link to a survey 1, 3 and 9 months after a diagnosis of EPL, and 1 month after the diagnosis of a viable ongoing pregnancy.

Setting

The Early Pregnancy Assessment Unit (EPAU) of a central London teaching hospital.

Participants

We recruited 186 women. 128 had a diagnosis of EPL, and 58 of ongoing pregnancies. 11 withdrew consent, and 11 provided an illegible or invalid email address.

Main outcome measures

Post-traumatic stress disorder (PTSD) was measured using the Post-traumatic Diagnostic Scale (PDS), and anxiety and depression using the Hospital Anxiety and Depression Scale (HADS).

Results

Response rates were 69/114 at 1 month and 44/68 at 3 months in the EPL group, and 20/50 in controls. Psychological morbidity was higher in the EPL group with 28% meeting the criteria for probable PTSD, 32% for anxiety and 16% for depression at 1 month and 38%, 20% and 5%, respectively, at 3 months. In the control group, no women met criteria for PTSD and 10% met criteria for anxiety and depression. There was little difference in type or severity of distress following ectopic pregnancy or miscarriage.

Conclusions

We have shown a large number of women having experienced a miscarriage or ectopic pregnancy fulfil the diagnostic criteria for probable PTSD. Many suffer from moderate-to-severe anxiety, and a lesser number depression. Psychological morbidity, and in particular PTSD symptoms, persists at least 3 months following pregnancy loss.

The present study investigated the effects of switching to different products of the same off-patent active substance (brand name or generic) on therapy discontinuation or substitution with another molecule of the same class, in patients with cardiovascular disease treated with statins and antihypertensives in a ‘real-world’ setting.

Design

A retrospective cohort study in a ‘real-world’ setting.

Setting

Analysis of data performed by integrating administrative databases that included approximately two million individuals who are assisted by the National Health System from three Local Health Units located in three different regions of Italy.

Participants

All patients aged ≥18 years with at least one prescription of simvastatin, ramipril or amlodipine in the period 1 January to 31 December 2010 were included and followed up for 2 years.

Main outcome measures

Prescription refills occurring during follow-up were evaluated. Frequency of discontinuation of therapy or substitution with another molecule of the same class (eg, from simvastatin to a different statin) during follow-up was identified.

Results

During follow-up, therapy discontinuation or substitution was found to be more frequent in patients switching to a different product of the same active substance compared with non-switching patients (11.5% vs 10.8% and 22.2% vs 20.8% (p=0.002), respectively, in the simvastatin group; 4.0% vs 3.5% and 24.6% vs 22.7% (p<0.001), respectively, in the amlodipine group). In the ramipril group, 8% of patients undertook a therapy substitution to another molecule; no trend towards a lower percentage of substitution was observed in the non-switching group, while 18% of patients discontinued treatment, with a significant difference in favour of patients not switching. These findings were partially confirmed by multivariate analysis.

Conclusions

Switches among products of the same active substance are quite common in patients with cardiovascular disease. Our study suggests that switching may expose patients to a higher risk of therapy discontinuation or substitution.

Between December 2014 and July 2015, semistructured interviews were conducted with 18 people with advanced cancer, all of whom had recently attended the ED of a large university teaching hospital located in south-east London; and six of their caregivers. Interviews were audio recorded, transcribed verbatim and analysed using a constant comparative approach. Padgett and Brodsky's modified version of the ‘Behavioral Model of Health Services Use’ was used as a framework to guide the study.

Results

Issues influencing the decision-making process included: (1) disease-related anxiety—those with greater anxiety related to their cancer diagnosis interpreted their symptoms as more severe and/or requiring immediate attention; (2) prior patterns of health-seeking behaviour—at times of crisis participants defaulted to previously used services; (3) feelings of safety and familiarity with the hospital setting—many felt reassured by the presence of healthcare professionals and monitoring of their condition; and, (4) difficulties accessing community healthcare services—especially urgently and/or out-of-hours.

Conclusions

These data provide healthcare professionals and policymakers with a greater understanding of how systems of care may be developed to help reduce ED visits by people with advanced cancer. In particular, our findings suggest that the number of ED visits could be reduced with greater end-of-life symptom support and education, earlier collaboration between oncology and palliative care, and with increased access to community healthcare services.

It is usually assumed that housing tenure and car access are associated with health simply because they are acting as markers for social class or income and wealth. However, previous studies conducted in the late 1990s found that these household assets were associated with health independently of social class and income. Here, we set out to examine if this is still the case.

Methods

We use data from our 2010 postal survey of a random sample of adults (n=2092) in 8 local authority areas in the West of Scotland. Self-reported health measures included limiting longstanding illness (LLSI), general health over the last year and the Hospital Anxiety and Depression Scale.

Results

We found a statistically significant relationship between housing tenure and all 4 health measures, regardless of the inclusion of social class or income as controls. Compared with owner occupiers, social renters were more likely to report ill-health (controlling for social class—LLSI OR: 3.24, general health OR: 2.82, anxiety 2: 0.031, depression 2: 0.048, controlling for income—LLSI OR: 3.28, general health OR: 2.82, anxiety 2: 0.033, depression 2: 0.057) (p<0.001 for all models). Car ownership was independently associated with depression and anxiety, with non-owners at higher risk of both (controlling for income—anxiety 2: 0.010, depression 2: 0.023, controlling for social class—anxiety 2: 0.013, depression 2: 0.033) (p<0.001 for all models).

Conclusions

Our results show that housing tenure and car ownership are still associated with health, after taking known correlates (age, sex, social class, income) into account. Further research is required to unpack some of the features of these household assets such as the quality of the dwelling and access to and use of different forms of transport to determine what health benefits or disbenefits they may be associated with in different contexts.

Alcohol consumption is steadily increasing in high-income countries but the harm and possible net benefits of light-to-moderate drinking remain controversial. We prospectively investigated the association between time-varying alcohol consumption and overall and cause-specific mortality among middle-aged women.

Methods

Among 48 249 women at baseline (33 404 at follow-up) in the prospective Swedish Women's Lifestyle and Health cohort, age 30–49 years at baseline, we used repeated information on alcohol consumption and combined this method with multiple imputation in order to maximise the number of participants and deaths included in the analyses. Multivariable Cox regression models were used to calculate HRs for overall and cause-specific mortality.

Results

During >900 000 person/years, a total of 2100 deaths were recorded through Swedish registries. The median alcohol consumption increased from 2.3 g/day in 1991/1992 (baseline) to 4.7 g/day in 2004 (follow-up). Compared with light drinkers (0.1–1.5 g/day), a null association was observed for all categories of alcohol consumption with the exception of never drinkers. The HR comparing never with light drinkers was 1.46 (95% CI 1.22 to 1.74). There was a statistically significant negative trend between increasing alcohol consumption and cardiovascular and ischaemic heart diseases mortality. The results were similar when women with prevalent conditions were excluded.

Conclusions

In conclusion, in a cohort of young women, light alcohol consumption was protective for cardiovascular and ischaemic heart disease mortality but not for cancer and overall mortality.

To compare iron stores in infants born after elective caesarean section (CS) and a 30 s delay of umbilical cord clamping with those born vaginally after early (≤10 s) or delayed (≥180 s) cord clamping.

Design

Prospective observational study with historical control.

Setting

Swedish county hospital.

Population

64 infants born after elective CS were compared with a historical control of 166 early clamped and 168 delayed clamped after vaginal birth.

Methods

Blood and iron status were measured in blood samples collected at birth, 48–96 hours after birth, 4 and 12 months of age.

Primary and secondary outcome measures

Ferritin at 4 months of age was the primary outcome, second outcome measures were other indicators of iron status, and haemoglobin, at 4 and 12 months of age, as well as respiratory distress at 1 and 6 hours after birth.

Results

At 4 months infants born by elective CS had better iron status than those born vaginally subjected to early cord clamping, shown by higher adjusted mean difference of ferritin concentration (39 µg/L (95% CI 10 to 60)) and mean cell volume (1.8 fL (95% CI 0.6 to 3.0)); and lower levels of transferrin receptors (–0.39 mg/L (95% CI –0.69 to –0.08)). No differences were seen between infants born after elective CS and delayed clamped vaginally born infants at 4 months. No differences were found between groups at 12 months of age.

Conclusions

Waiting to clamp the umbilical cord for 30 s after elective CS results in higher iron stores at 4 months of age compared with early cord clamping after vaginal birth, and seems to ensure iron status comparable with those achieved after 180 s delayed cord clamping after vaginal birth.

Malocclusion is a highly prevalent condition, affecting 20–60% of adolescents worldwide. Although its treatment is often expensive and unaffordable for disadvantaged individuals, few studies have examined the relationship between malocclusion and socioeconomic status. We investigated the prevalence of malocclusion among Mongolian adolescents and its association with maternal education in a community-based sample in Mongolia.

Design

Cross-sectional study.

Settings

2 large secondary schools with different backgrounds in Ulaanbaatar, Mongolia.

Participants

Complete dental casts of 557 randomly recruited Mongolian schoolchildren aged 11–16 years were evaluated using the Dental Health Component of the Index of Orthodontic Treatment Need to dichotomise orthodontic treatment requirements. Exclusion criteria were the presence of orthodontic treatment history and absence of maternal educational status. Questionnaires were administered to caregivers to assess socioeconomic status. Poisson regression analysis was performed to examine the association between malocclusion and maternal educational status.

Results

The prevalence of malocclusion requiring orthodontic treatment among all adolescents was 35.2% (95% CI 31.2 to 39.2). In the unadjusted analysis, the prevalence ratio (PR) for malocclusion was higher (PR=1.46; 95% CI 0.96 to 2.20) among adolescents of mothers with a high educational background than among those of mothers with a low educational background. After adjusting for covariates, the PR remained significantly higher (PR=1.72; 95% CI 1.06 to 2.82) among adolescents of mothers with a high educational background. Other socioeconomic status variables, including family income and the educational level of the father, showed no association with malocclusion.

Conclusions

These findings suggest that malocclusion requiring orthodontic treatment in adolescents is more prevalent among children of mothers with high levels of education. Further studies are needed to clarify the behavioural factors and environmental circumstance that contribute to this.

Switzerland has mountains and valleys complicating the access to a hospital and critical care in case of emergencies. Treatment success for acute myocardial infarction (AMI) or stroke depends on timely treatment. We examined the relationship between distance to different hospital types and mortality from AMI or stroke in the Swiss National Cohort (SNC) Study.

Design and setting

The SNC is a longitudinal mortality study of the census 2000 population of Switzerland. For 4.5 million Swiss residents not living in a nursing home and older than 30 years in the year 2000, we calculated driving time and straight-line distance from their home to the nearest acute, acute with emergency room, central and university hospital (in total 173 hospitals). On the basis of quintiles, we used multivariable Cox proportional hazard models to estimate HRs of AMI and stroke mortality for driving time distance groups compared to the closest distance group.

Results

Over 8 years, 19 301 AMI and 21 931 stroke deaths occurred. Mean driving time to the nearest acute hospital was 6.5 min (29.7 min to a university hospital). For AMI mortality, driving time to a university hospital showed the strongest association among the four types of hospitals with a hazard ratio (HR) of 1.19 (95% CI 1.10 to 1.30) and 1.10 (95% CI 1.01 to 1.20) for men and women aged 65+ years when comparing the highest quintile with the lowest quintile of driving time. For stroke mortality, the association with university hospital driving time was less pronounced than for AMI mortality and did not show a clear incremental pattern with increasing driving time. There was no association with driving time to the nearest hospital.

Conclusions

The increasing AMI mortality with increasing driving time to the nearest university hospital but not to any nearest hospital reflects a complex interplay of many factors along the care pathway.

This study was designed to investigate the effect of alcohol intoxication on clinical presentation of hospitalised adult trauma patients at a Level I trauma centre using propensity score matching.

Design

Cross-sectional study.

Setting

Taiwan.

Participants

Detailed data of 929 hospitalised adult trauma patients with alcohol intoxication, aged 20–65 years, and 10 104 corresponding patients without alcohol intoxication were retrieved from the Trauma Registry System between 1 January 2009 and 31 December 2014. Alcohol intoxication was defined as a blood alcohol concentration (BAC) ≥50 mg/dL.

Main outcome measures

In-hospital mortality and expenditure.

Results

Patients with alcohol intoxication presented with significantly higher short-term mortality (OR: 3.0, 95% CI 2.0 to 4.4; p<0.001) than patients without alcohol intoxication. However, on comparison with propensity score-matched patients with respect to sex, age, comorbidity, Glasgow Coma Scale (GCS), injury region based on Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS), alcohol intoxication did not significantly influence mortality (OR: 0.8, 95% CI 0.5 to 1.4; p=0.563). This implied that the higher mortality of alcohol-intoxicated patients was attributable to patient characteristics such as a higher injury severity rather than alcohol intoxication. Even on comparison with sex-matched, age-matched and comorbidity-matched patients without alcohol intoxication, patients with alcohol intoxication still had significantly higher total expenditure (17.4% higher), cost of operation (40.3% higher), cost of examination (52.8% higher) and cost of pharmaceuticals (38.3% higher).

Conclusions

The associated higher mortality of adult trauma patients with alcohol intoxication was completely attributable to other patient characteristics and associated injury severity rather than the effects of alcohol. However, patients with alcohol intoxication incurred significantly higher expenditure than patients without alcohol intoxication, even on comparison with sex-matched, age-matched and comorbidity-matched patients without alcohol intoxication.

To understand patient engagement with decision-making for infection management in secondary care and the consequences associated with current practices.

Design

A qualitative investigation using in-depth focus groups.

Participants

Fourteen members of the public who had received antimicrobials from secondary care in the preceding 12 months in the UK were identified for recruitment. Ten agreed to participate. All participants had experience of infection management in secondary care pathways across a variety of South-East England healthcare institutes. Study findings were subsequently tested through follow-up focus groups with 20 newly recruited citizens.

Results

Participants reported feelings of disempowerment during episodes of infection in secondary care. Information is communicated in a unilateral manner with individuals ‘told’ that they have an infection and will receive an antimicrobial (often unnamed), leading to loss of ownership, frustration, anxiety and ultimately distancing them from engaging with decision-making. This poor communication drives individuals to seek information from alternative sources, including online, which is associated with concerns over reliability and individualisation. Failures in communication and information provision by clinicians in secondary care influence individuals’ future ideas about infections and their management. This alters their future actions towards antimicrobials and can drive prescription non-adherence and loss to follow-up.

Conclusions

Current infection management and antimicrobial prescribing practices in secondary care fail to engage patients with the decision-making process. Secondary care physicians must not view infection management episodes as discrete events, but as cumulative experiences which have the potential to shape future patient behaviour and understanding of antimicrobial use.

Effect of the interventions on the prevalence of anaemia (haemoglobin <110 g/L) and stunting (z-score of height-for-age <–2.0) (controlled for differences between the counties), and on infant feeding practices.

Results

The surveys were conducted on 1804, 2187 and 2186 children aged 6–23 months in the intervention county in August 2012, 2013 and 2014, respectively, and 804, 680 and 790 children in the control county, respectively. Between the baseline and end-line surveys, anaemia prevalence decreased more in the intervention county than in the control county (71.1% to 47.8% vs 86.3% to 75.3%, respectively; p<0.0001). There was no difference in the decrease in stunting prevalence between the counties (9.7% to 7.1% vs 17.0% to 15.0%; p=0.7954). The proportions of children given iron-rich or iron-fortified food, introduced to (semi-) solid food at 6–8 months, and given food with minimum dietary diversity increased from 43.2% to 88.8% (p<0.0001), 81.4% to 96% (p=0.0470) and 53.0% to 59.8% (p<0.0001), respectively in the intervention county.

Conclusions

We found much higher anaemia prevalence in poor rural areas of Qinghai Province compared with the national data. Community-based complementary food supplements combined with dietary counselling can improve feeding practices and reduce anaemia prevalence. Future studies should use longer follow-up to assess the effects on stunting.

Strengths and limitations

We included a large number of participants and assessed a combined complementary food supplements and dietary counselling intervention in a poor rural area in China with high anaemia prevalence. Although the study took place in only one intervention county and one control county, we conducted an analysis that controlled for differences between the two counties. Also, although we made significant efforts to train village doctors, their education was not systematically assessed after training and thus their delivery of the interventions may have been variable.

To describe the effect of in utero exposure to the buprenorphine+naloxone combination product in a rural and remote population.

Setting

A district hospital that services rural and remote, fly-in communities in Northwestern Ontario, Canada.

Participants

A retrospective cohort study was conducted of 855 mother infant dyads between 1 July 2013 and 30 June 2015. Cases included all women who had exposure to buprenorphine+naloxone during pregnancy (n=62). 2 control groups were identified; the first included women with no opioid exposure in pregnancy (n=618) and the second included women with opioid exposure other than buprenorphine+naloxone (n=159). Women were excluded if they had multiple pregnancy or if they were part of a methadone programme (n=16). The majority of women came from Indigenous communities.

Outcomes

The primary outcomes were birth weight, preterm delivery, congenital anomalies and stillbirth. Secondary neonatal outcomes included gestational age at delivery, Apgar scores at 1 and 5 min, NAS Score >7 and treatment for neonatal abstinence syndrome (NAS). Secondary maternal outcomes included the number of caesarean sections, postpartum haemorrhages, out of hospital deliveries and transfer of care to tertiary centres.

Results

No difference was found in the primary outcomes or in the Apgar score and caesarean section rate between in utero buprenorphine+naloxone exposure versus no opioid exposure in pregnancy. Compared to women taking other opioids, women taking buprenorphine+naloxone had higher birthweight babies (p=0.001) and less exposure to marijuana (p<0.001) during pregnancy.

Conclusions

Retrospective data suggest that there likely is no harm from taking buprenorphine+naloxone opioid agonist treatment in pregnancy. Larger, prospective studies are needed to further assess safety.

To estimate total and cause-specific mortality after international peacekeeping deployments among the Finnish military peacekeeping personnel in comparison to the general population of similar age and sex.

Design

A register-based study of a cohort of military peacekeeping personnel in 1990–2010 followed for mortality until the end of 2013. Causes of death were obtained from the national Causes of Death Register. The standardised mortality ratio (SMR) for total and cause-specific mortality was calculated as the ratio of observed and expected number of deaths.

Setting

Finland (peacekeeping operations in different countries in Africa, Asia and in an area of former Yugoslavia in Europe).

Participants

14 584 men and 418 women who had participated in international military peacekeeping operations ending between 1990 and 2010.

Interventions

Participation in military peacekeeping operations.

Main outcome

Total and cause-specific mortality.

Results

209 men and 3 women died after their peacekeeping service. The SMR for all-cause mortality was 0.55 (95% CI 0.48 to 0.62). For the male peacekeeping personnel, the SMR for all diseases was 0.44 (95% CI 0.35 to 0.53) and for accidental and violent deaths 0.69 (95% CI 0.57 to 0.82). The SMR for suicides was 0.71 (95% CI 0.53 to 0.92).

Conclusions

Even though military peacekeeping personnel are working in unique and often stressful conditions, their mortality after their service is lower compared with the general population. Military peacekeeping personnel appear to be a selected population group with low general mortality and no excess risk of any cause of death after peacekeeping service.

To assess the impact of initiatives aiming to increase clinician awareness of radiation exposure; to explore the challenges they face when communicating with patients; to study what they think is the most appropriate way of communicating the long-term potential risks of medical radiological exposure to patients.

Design

A quantitative and qualitative evaluation through a survey and focal groups.

The surveys were answered (a) in person (216: all the radiologists (30), urologists (14) and surgeons (44) working at both participant hospitals; a sample of general practitioners from the catchment area of one hospital (45), and a consecutive sample of radiologists attending a scientific meeting (60)) or (b) electronically through Spanish scientific societies (299: radiologists (45), pneumologists (123), haematologists (75) and surgeons (40)). Clinicians were not randomly selected and thus the results are limited by the diligence of the individuals filling out the survey.

Primary and secondary outcome measures

Clinicians' knowledge and practices regarding medical radiological exposure, and what they considered most appropriate for communicating information to patients.

Results

Nearly 80% of the clinicians surveyed had never heard of the European recommendations. Fewer than 20% of the clinicians surveyed identified correctly the radiation equivalence dose of intravenous urography or barium enema. It was reported by 31.7% that they inform patients about the long-term potential risks of ionising radiation. All participants agreed that the most appropriate way to present information is a table with a list of imaging tests and their corresponding radiation equivalence dose in terms of chest X-rays and background radiation exposure.

Conclusions

Medical radiological exposure is frequently underestimated and rarely explained to patients. With a clear understanding of medical radiological exposure and proper communication tools, clinicians will be able to accurately inform patients.

There is controversy on the proposed benefits of publishing mortality rates for individual surgeons. In some procedures, analysis at the level of an individual surgeon may lack statistical power. The aim was to determine the likelihood that variation in surgeon performance will be detected using published outcome data.

Design

A national analysis surgeon-level mortality rates to calculate the level of power for the reported mortality rate across multiple surgical procedures.

The likelihood of detecting an individual with a 30-day, 90-day or in-patient mortality rate of up to 5 times the national mean or median (as available). This was represented using a novel heat-map approach.

Results

Overall mortality rates for the procedures ranged from 0.07% to 4.5% and mean/median surgeon volume was between 23 and 75 cases. The national median case volume for colorectal (n=55) and upper gastrointestinal (n=23) cancer resections provides around 20% power to detect a mortality rate of 3 times the national median, while, for hip replacement, this is a rate 5 times the national average. At the mortality rates reported for thyroid (0.08%) and bariatric (0.07%) procedures, it is unlikely a surgeon would perform a sufficient number of procedures in his/her entire career to stand a good chance of detecting a mortality rate 5 times the national average.

Conclusions

At present, surgeons with increased mortality rates are unlikely to be detected. Performance within an expected mortality rate range cannot be considered reliable evidence of acceptable performance. Alternative approaches should focus on commonly occurring meaningful outcome measures, with infrequent events analysed predominately at the hospital level.

The objective of this article is to explore the educational needs and design aspects of personalised internet-enabled education for patients with diabetes in Iran.

Design

Data were collected using semistructured interviews and then qualitatively analysed using inductive content analysis.

Participants

9 patients with type 2 diabetes were included. Inclusion criteria were access to and knowledge on how to use the internet. The selection ensured representation based on gender, age, occupation and educational background.

Setting

The sample population was patients with diabetes who were admitted to an outpatient diabetes clinic in Mashhad, a large city of Iran with about 3 million inhabitants.

Results

4 core categories emerged from the data: (1) seeking knowledge about diabetes, including specific knowledge acquisition, patient's interactions and learning requirements; (2) teaching and learning, including using different teaching methods and different ways to learn about the disease; (3) facilitators, including internet and mobile phone use to learn about the disease; and (4) barriers, including lack of internet access, uncertainty of access to the internet and lack of website in the local language and also perceived cultural barriers, such as patients' fears of the internet, lack of time and awareness.

Conclusions

This study provides a better understanding of the patient's educational expectations and technical needs in relation to internet-enabled education. This knowledge will inform the development of functional mock-ups in the next research phase using a design-based research approach in order to design internet-enabled patient education for self-management of diabetes.

With immigration and minority populations rapidly growing in the USA, it is critical to assess how these populations fare after immigration, and in subsequent generations. Our aim is to compare death rates and cause of death across foreign-born, US-born and country of origin Chinese and Japanese populations.

Methods

We analysed all-cause and cause-specific age-standardised mortality rates and trends using 2003–2011 US death record data for Chinese and Japanese decedents aged 25 or older by nativity status and sex, and used the WHO Mortality Database for Hong Kong and Japan decedents in the same years. Characteristics such as age at death, absolute number of deaths by cause and educational attainment were also reported.

Results

We examined a total of 10 458 849 deaths. All-cause mortality was highest in Hong Kong and Japan, intermediate for foreign-born, and lowest for US-born decedents. Improved mortality outcomes and higher educational attainment among foreign-born were observed compared with developed Asia counterparts. Lower rates in US-born decedents were due to decreased cancer and communicable disease mortality rates in the US heart disease mortality was either similar or slightly higher among Chinese-Americans and Japanese-Americans compared with those in developed Asia counterparts.

Conclusions

Mortality advantages in the USA were largely due to improvements in cancer and communicable disease mortality outcomes. Mortality advantages and higher educational attainments for foreign-born populations compared with developed Asia counterparts may suggest selective migration. Findings add to our limited understanding of the racial and environmental contributions to immigrant health disparities.

Patients were divided into 2 groups based on the results of an initial peritoneal equilibration test performed within 3 months of starting PD therapy: group 1 consisted of low/low average transporters (n=123), and group 2 consisted of high/high average transporters (n=97). We genotyped TIE2 and IL-6 polymorphisms and analysed their effects on baseline transport status.

Results

The genotype AT in IL-6 Rs13306435 and the genotype CC in TIE2 Rs639225 were both negatively associated with a higher initial peritoneal transport status (IL-6 Rs13306435: OR=0.408, 95% CI 0.227 to 0.736; TIE2 Rs639225: OR=0.188, 95% CI 0.044 to 0.806).

To investigate the association between the difficulty in hospital acceptance at the scene by emergency medical service (EMS) personnel and prehospital demographic factors and reasons for EMS calls.

Design

A retrospective, observational study.

Setting

Osaka City, Japan.

Participants

A total of 100 649 patients transported to medical institutions by EMS from January 2013 to December 2013.

Primary outcome measurements

The definition of difficulty in hospital acceptance at the scene was EMS personnel making ≥5 phone calls to medical institutions until a decision to transport was determined. Multivariable analysis was used to assess the relationship between difficulty in hospital acceptance and prehospital factors and reasons for EMS calls.

Results

Multivariable analysis showed the elderly, foreigners, loss of consciousness, holiday/weekend, and night-time to be positively associated with difficulty in hospital acceptance at the scene. As reasons for EMS calls, gas poisoning (adjusted OR 3.281, 95% CI 1.201 to 8.965), trauma by assault (adjusted OR 2.662, 95% CI 2.390 to 2.966), self-induced drug abuse/gas poisoning (adjusted OR 4.527, 95% CI 3.921 to 5.228) and self-induced trauma (adjusted OR 1.708, 95% CI 1.369 to 2.130) were positively associated with the difficulty in hospital acceptance at the scene.

Conclusions

Ambulance records in Osaka City showed that certain prehospital factors such as night-time were positively associated with difficulty in hospital acceptance at the scene, and reasons for EMS calls, such as self-induced drug abuse/gas poisoning, were also positive predictors for difficulty in hospital acceptance at the scene.

Overall, 99% (GRRS) and 100% (MECS) patients were satisfied with their optometrists’ examination. The vast majority rated the following as ‘very good’; examination duration, optometrists’ listening skills, explanations of tests and management, patient involvement in decision-making, treating the patient with care and concern. 99% of MECS patients would recommend the service. Manchester optometrists were enthusiastic about GRRS, feeling fortunate to practise in a ‘pro-optometry’ area. No major negatives were reported, although both schemes were limited to patients resident within certain postcode areas, and some inappropriate GP referrals occurred (MECS). Communication with hospitals was praised in GRRS but was variable, depending on hospital (MECS). Training for both schemes was valuable and appropriate but should be ongoing. MECS GPs were very supportive, reporting the scheme would reduce secondary care referral numbers, although some MECS patients were referred back to GPs for medication. Ophthalmologists (MECS and GRRS) expressed very positive views and widely acknowledged that these new care pathways would reduce unnecessary referrals and shorten patient waiting times. Commissioners felt both schemes met or exceeded expectations in terms of quality of care, allowing patients to be seen quicker and more efficiently.

Conclusions

Locally commissioned schemes can be a positive experience for all involved. With appropriate training, clear referral pathways and good communication, community optometrists can offer high-quality services that are highly acceptable to patients, health professionals and commissioners.

The purpose of this study was to evaluate the impact of a 4-week walking intervention on subjective sleep quality.

Design

A prospective open-label study.

Participants

A total of 490 healthy workers were included in the study. The 490 participants were divided into a group of 214 participants with exercise habits (exercising group, EG) and a group of 276 participants without exercise habits (non-EG).

Interventions

A walking intervention with a target of walking 10 000 steps daily for 4 weeks.

Outcome measures

The Pittsburgh Sleep Quality Index (PSQI) questionnaire was administered twice (before the start and after the end of the study).

35 physicians who had >30 successful ETI experiences at a tertiary hospital in Seoul, Korea.

Primary and secondary outcome measures

Participants performed ETI using PAWS, GVL and DL randomly in simulated MILS, PNC and SNC scenarios in our simulation centre. The end points were successful ETI and the time to complete ETI. In addition, modified Cormack-Lehane (CL) classification and pressure to teeth were recorded.

Results

In MILS, there were no significant differences in the rate of success of ETI between the three devices: 33/35(94.3%) for DL vs 32/35(91.4%) for GVL vs 35/35(100.0%) for PAWS; p=0.230). PAWS achieved successful ETI more quickly (19.8 s) than DL (29.6 s) and GVL (35.4 s). For the PNC scenario, a higher rate of successful ETI was achieved with GVL 33/35 (94.3%) than PAWS 29/35 (82.9%) or DL 25/35 (71.4%) (p=0.040). For the SNC scenario, a higher rate of successful ETI was achieved with GVL 28/35(80.0%) than with DL 14/35(40.0%) and PAWS 7/35(20.0%) (p<0.001). For the PNC and SNC scenarios, GVL provided a relatively good view of the glottis, but a frequent pressure to teeth occurred.

Conclusions

All three devices are suitable for ETI in MILS. DL is not suitable in both neck collar scenarios. PAWS showed faster intubations in MILS, but was not suitable in the SNC scenario. GVL is most suitable in all cervical immobilisation scenarios, but may cause pressure to teeth more frequently.

To assess the cost-effectiveness of optometrist-led follow-up monitoring reviews for patients with quiescent neovascular age-related macular degeneration (nAMD) in community settings (including high street opticians) compared with ophthalmologist-led reviews in hospitals.

Design

A model-based cost-effectiveness analysis with a 4-week time horizon, based on a ‘virtual’ non-inferiority randomised trial designed to emulate a parallel group design.

The participating optometrists and ophthalmologists classified lesions from vignettes and were asked to judge whether any retreatment was required. Vignettes comprised clinical information, colour fundus photographs and optical coherence tomography images. Participants' classifications were validated against experts' classifications (reference standard). Resource use and cost information were attributed to these retreatment decisions.

Main outcome measures

Correct classification of whether further treatment is needed, compared with a reference standard.

Results

The mean cost per assessment, including the subsequent care pathway, was £411 for optometrists and £397 for ophthalmologists: a cost difference of £13 (95% CI –£18 to £45). Optometrists were non-inferior to ophthalmologists with respect to the overall percentage of lesions correctly assessed (difference –1.0%; 95% CI –4.5% to 2.5%).

Conclusions

In the base case analysis, the slightly larger number of incorrect retreatment decisions by optometrists led to marginally and non-significantly higher costs. Sensitivity analyses that reflected different practices across eye hospitals indicate that shared care pathways between optometrists and ophthalmologists can be identified which may reduce demands on scant hospital resources, although in light of the uncertainty around differences in outcome and cost it remains unclear whether the differences between the 2 care pathways are significant in economic terms.

17 devote Christians with an ethnic-Swedish background, 12 women and 5 men, 30–73 years old, from different congregations across Sweden, having sought medical care for mental ill health of any kind.

Setting

The secular Swedish society.

Results

A living, although asymmetric, relationship with God often was seen as the most important relationship, giving hope and support when ill, but creating feelings of abandonment and fear if perceived as threatened. Symptoms were interpreted through an existential framework influenced by their view of God. A perceived judging God increased feelings of guilt, sinfulness and shame. A perceived merciful God soothed symptoms and promoted recovery. Existential consequences, such as being unable to pray or participate in congregational rituals, caused feelings of ‘spiritual homelessness’. Participants gave biopsychosocial explanations of their mental ill health, consonant with and sometimes painfully conflicting with existential explanations, such as being attacked by demons. Three different patterns of interaction among biopsychosocial and existential dimensions in their explanatory systems of illness causation were identified: (a) comprehensive thinking and consensus; (b) division and parallel functions and (c) division and competitive functions.

Conclusions

Prevailing medical models for understanding mental ill health do not include the individual's existential experiences, which are important for identifying risk and protective factors as well as possible resources for recovery. The various expressions of existential meaning-making identified in this devout religious subgroup illustrate that existential information cannot be generalised, even within a small, seemingly homogenous group. The three identified patterns of interactions formed a typology that may be of use in clinical settings.

To evaluate if a referral intervention improves the patient experience of the referral and treatment process.

Setting

Interface between 14 primary care surgeries and a district general hospital.

Participants

The 14 general practitioner (GP) surgeries (7 intervention, 7 control) in the area around the University Hospital of North Norway Harstad were randomised and all completed the study. Consecutive individual patients were recruited at their hospital appointment. A total of 500 patients were recruited with 281 in the intervention and 219 in the control arm.

Interventions

Dissemination of referral templates for 4 diagnostic groups (dyspepsia, suspected colorectal cancer, chest pain and chronic obstructive pulmonary disease) coupled with intermittent surgery visits by study personnel. The control arm continued standard referral practice. The intervention was in use for 2.5 years.

Outcome

The main outcome was a quality indicator score. This paper reports a secondary outcome, the patient experience, as measured by self-report questionnaires. GPs in the intervention group could not be blinded. Patients were blinded to intervention status. Analysis was based on single-question comparison with a questionnaire subscore used to assess the effect of clustering.

Results

On the individual questions, overall satisfaction was very high with minor differences between the intervention and control group. Interestingly, the most negative responses, in both groups concerned questions relating to patient interaction and information. Very little evidence of clustering was found with an estimated intracluster correlations coefficient at 1.21e–11.

Conclusions

In total, this indicates no clear effect of the implementation of referral templates on the patient experience, in a setting of generally high patient satisfaction.

To investigate the impact of service redesign in the provision of revascularisation procedures on the historical socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction (AMI).

9128 participants admitted to an NHS hospital with a first AMI between 1 January 2010 and 30 June 2013, with 6-months follow-up.

Main outcome measure

Hazard ratios (HRs) for the time to revascularisation for deprivation quintiles, age, gender, comorbidities, rural–urban classification and revascularisation facilities of admitting hospital.

Results

In the preintervention period, there was a statistically significant decreased adjusted risk of revascularisation for participants in the most deprived quintile compared to the least deprived quintile (HR 0.80; 95% CI 0.69 to 0.92, p=0.002). In the postintervention period, the increase in revascularisation rates was statistically significant in all quintiles, and there was no longer any statistically significant difference in the adjusted revascularisation risk between the most and the least deprived quintile (HR 1.04; 95% CI 0.89 to 1.20, p<0.649). However, inequity persisted for those aged 75 years and over (HR 0.40; 95% CI 0.35 to 0.46, p<0.001) and women (HR 0.77; 95% CI 0.70 to 0.86, p<0.001).

Conclusions

Socioeconomic inequity of access to revascularisation was no longer apparent following redesign of revascularisation services in the south Wales cardiac network, although inequity persisted for women and those aged 75+ years. Increasing the capacity of revascularisation did not differentially benefit participants from the least deprived areas.

To examine how the breastfeeding experience is represented by users of FeedFinder (a mobile phone application for finding, reviewing and sharing places to breastfeed in public).

Design

Content analysis using FeedFinder database.

Setting

FeedFinder, UK, September 2013–June 2015.

Methods

Reviews obtained through FeedFinder over a period of 21 months were systematically coded using a conventional content analysis approach, average review scores were calculated for the rating criteria in FeedFinder (comfort, hygiene, privacy, baby facilities) and review texts were analysed for sentiment. We used data from Foursquare to describe the type of venues visited and cross-referenced the location of venues with the Indices of Multiple Deprivation.

Results

A total of 1757 reviews were analysed. Of all the reviews obtained, 80% of those were classified as positive, 15.4% were classified as neutral and 4.3% were classified as negative. Important factors that were discussed by women include facilities, service, level of privacy available and qualities of a venue. The majority of venues were classified as cafes (26.4%), shops (24.4%) and pubs (13.4%). Data on IMD were available for 1229 venues mapped within FeedFinder, 23% were located within the most deprived quintile and 16% were located in the least deprived quintile.

Conclusions

Women create content that is positive and informative when describing their breastfeeding experience in public. Public health bodies and business owners have the potential to use the data from FeedFinder to impact on service provision. Further work is needed to explore the demographic differences that may help to tailor public health interventions aimed at increasing breastfeeding rates in the UK.

Historically, alcohol use and related harms are more prevalent in men than in women. However, emerging evidence suggests the epidemiology of alcohol use is changing in younger cohorts. The current study aimed to systematically summarise published literature on birth cohort changes in male-to-female ratios in indicators of alcohol use and related harms.

There was a linear decrease over time in the sex ratio for all 3 categories of alcohol use and related harms. Among those born in the early 1900s, males were 2.2 (95% CI 1.9 to 2.5) times more likely than females to consume alcohol, 3.0 (95% CI 1.5 to 6.0) times more likely to drink alcohol in ways suggestive of problematic use and 3.6 (95% CI 0.4 to 30.3) times more likely to experience alcohol-related harms. Among cohorts born in the late 1900s, males were 1.1 (95% CI 1.1 to 1.2) times more likely than females to consume alcohol, 1.2 (95% CI 1.1 to 1.4) times more likely to drink alcohol in ways suggestive of problematic use and 1.3 (95% CI 1.2 to 1.3) times more likely to experience alcohol-related harms.

Conclusions

Findings confirm the closing male–female gap in indicators of alcohol use and related harms. The closing male–female gap is most evident among young adults, highlighting the importance of prospectively tracking young male and female cohorts as they age into their 30s, 40s and beyond.

Assess the impact of text-based electronic notifications on improving clinic attendance, in relation to study quality (according to risk of bias), and to assess simple ways in which notifications can be optimised (ie, impact of multiple notifications).

MEDLINE, EMBASE, PsycINFO, Web of Science and Cochrane Database of Systematic Reviews (01.01.05 until 25.4.15). A systematic search to discover all studies containing quantitative data for synthesis into meta-analyses.

Eligibility criteria

Studies examining the effect of text-based electronic notifications on prescheduled appointment attendance in healthcare settings. Primary analysis included experimental studies where randomisation was used to define allocation to intervention and where a control group consisting of ‘no reminders’ was used. Secondary meta-analysis included studies comparing text reminders with voice reminders. Studies lacking sufficient information for inclusion (after attempting to contact study authors) were excluded.

Outcome measures

Primary outcomes were rate of attendance/non-attendance at healthcare appointments. Secondary outcome was rate of rescheduled and cancelled appointments.

Results

26 articles were included. 21 included in the primary meta-analysis (8345 patients receiving electronic text notifications, 7731 patients receiving no notifications). Studies were included from Europe (9), Asia (7), Africa (2), Australia (2) and America (1). Patients who received notifications were 23% more likely to attend clinic than those who received no notification (risk ratio=1.23, 67% vs 54%). Those receiving notifications were 25% less likely to ‘no show’ for appointments (risk ratio=.75, 15% vs 21%). Results were similar when accounting for risk of bias, region and publication year. Multiple notifications were significantly more effective at improving attendance than single notifications. Voice notifications appeared more effective than text notifications at improving attendance.

More than half the GP respondents to the survey in Australia self-reported that they would prescribe antibiotics for an URTI to meet patient expectations. Our qualitative findings suggest that ‘patient expectations’ may be the main reason given for inappropriate prescribing, but it is an all-encompassing phrase that includes other reasons. These include limited time, poor doctor–patient communication and diagnostic uncertainty. We have identified three role archetypes to explain the behaviour of GPs in reference to antibiotic prescribing for URTIs. The main themes emerging from the qualitative component was that many GPs did not think that antibiotic prescribing in primary care was responsible for the development of antibiotic resistance nor that their individual prescribing would make any difference in light of other bigger issues like hospital prescribing or veterinary use. For them, there were negligible negative consequences from their inappropriate prescribing.

Conclusions

There is a need to increase awareness of the scope and magnitude of antibiotic resistance and the role primary care prescribing plays, and of the contribution of individual prescribing decisions to the problem of antibiotic resistance.

To determine the amount of daily screen time in children 18 months of age and ascertain correlations that may be contributing to excessive screen use.

Design

A birth cohort was followed with telephone interviews at 6, 12 and 18 months of age. Information about screen time was collected at 18 months.

Setting

Parents were recruited from postnatal wards of 2 major public hospitals and at home visits conducted for new mothers within 4 weeks of birth in South Western Sydney (SWS).

Participants

Parents of 500 children with infants 18 months of age residing in SWS.

Primary and secondary outcomes

Screen time in infants 18 months of age and associated correlations.

Results

A large percentage of children 18 months of age (40%) had screen times >2 hours daily. There were significant associations between more than 2 hours of screen time daily and mothers without a partner (OR 4.32 (95% CI 1.67 to 11.15)); having <3 siblings (no siblings: OR 2.44 (95% CI 1.20 to 4.94); 1–2 siblings: OR 2.08 (95% CI 1.06 to 4.08)); an employed father (OR 1.96 (95% CI 1.09 to 3.52)); no outdoor equipment at home (OR 1.89 (95% CI 1.08 to 3.34)) and fewer than 5 outings per week (OR 2.08 (95% CI 1.37 to 3.17)).

Conclusions

There is emerging evidence that excess screen time in children causes adverse cognitive, developmental and health outcomes. This study has shown that a large proportion of very young children residing in SWS have screen exposures for >2 hours per day. Factors contributing to excess screen time have also been identified in this study; however, a greater understanding of risk factors needs to be ascertained in order to facilitate greater public health efforts to reduce screen exposure.

We compared 2 sociocultural cohorts with different duration of exposure to graphic health warning labels (GHWL), to investigate a possible desensitisation to their use. We further studied how a differing awareness and emotional impact of smoking-associated risks could be used to prevent this.

Setting

Structured interviews of patients from the general respiratory department were undertaken between 2012 and 2013 in 2 tertiary hospitals in Singapore and London.

Singaporeans scored lower than the Londoners across all label processing constructs, and this was consistent for the smoking and non-smoking groups. Londoners experienced more ‘disgust’ and felt GHWL were more effective at preventing initiation of, or quitting, smoking. Singaporeans had a lower awareness of lung cancer (82% vs 96%, p<0.001), despite ranking it as the most deterring consequence of smoking. Overall, ‘blindness’ was the least known potential risk (28%), despite being ranked as more deterring than ‘stroke’ and ‘oral cancer’ in all participants.

Conclusions

The length of exposure to GHWL impacts on the effectiveness. However, acknowledging the different levels of awareness and emotional impact of smoking-associated risks within different sociocultural cohorts could be used to maintain their impact.

To examine the funding for cerebral palsy (CP) research in Australia, as compared with the National Institutes of Health (NIH).

Design

Observational study.

Setting

For Australia, philanthropic funding from Cerebral Palsy Alliance Research Foundation (CPARF) (2005–2015) was compared with National Health and Medical Research Council (NHMRC, 2000–2015) and Australian Research Council (ARC, 2004–2015) and CPARF and NHMRC funding were compared with NIH funding (USA).

Participants

Cerebral Palsy researchers funded by CPARF, NHMRC or NIH.

Results

Over 10 years, total CPARF philanthropic funding was $21.9 million, including people, infrastructure, strategic and project support. As competitive grants, CPARF funded $11.1 million, NHMRC funded $53.5 million and Australian Research Council funded $1.5 million. CPARF, NHMRC and NIH funding has increased in real terms, but only the NIH statistically significantly increased in real terms (mean annual increase US$4.9 million per year, 95% CI 3.6 to 6.2, p<0.001). The NHMRC budget allocated to CP research remained steady over time at 0.5%. A network analysis indicated the relatively small number of CP researchers in Australia is mostly connected through CPARF or NHMRC funding.

Conclusions

Funding for CP research from the Australian government schemes has stabilised and CP researchers rely on philanthropic funding to fill this gap. In comparison, the NIH is funding a larger number of CP researchers and their funding pattern is consistently increasing.

As the predominant approach to acute reperfusion for ST segment elevation myocardial infarction (STEMI) in many countries, fibrinolytic therapy provides a relative risk reduction for death of ~16% across the range of baseline risk. For patients with low baseline mortality risk, fibrinolytic therapy may therefore provide little benefit, which may be offset by the risk of major bleeding. We aimed to construct a tool to determine if it is possible to identify a low-risk group among fibrinolytic therapy-eligible patients.

3741 patients with STEMI who were fibrinolytic-eligible but did not receive reperfusion therapy.

Main outcome measures

In-hospital mortality, which was defined as a composite of death occurring within hospitalisation or withdrawal from treatment due to a terminal status at discharge.

Results

In the study cohort, the in-hospital mortality was 14.7%. In the derivation cohort and the validation cohort, the combination of systolic blood pressure (≥100 mm Hg), age (<60 years old) and gender (male) identified one-fifth of the cohort with an average mortality rate of <3.0%. Half of this low risk group—those with non-anterior AMI—had an average in-hospital death risk of 1.5%.

Conclusions

Nearly, one in five patients with STEMI who are eligible for fibrinolytic therapy are at a low risk for in-hospital death. Three simple factors available at the time of presentation can identify these individuals and support decision-making about the use of fibrinolytic therapy.

In Japan, public health nurses (PHNs) play important roles in managing the health of local residents, especially after a disaster. In this study, we assessed radiation anxiety and the stress processing capacity of PHNs in the Fukushima Prefecture in Japan, after the accident at the Fukushima Daiichi Nuclear Power Station (FDNPS).

Methods

We conducted a questionnaire survey among the PHNs (n=430) in July of 2015 via postal mail. The questions included demographic factors (sex, age and employment position), knowledge about radiation, degree of anxiety about radiation at the time of the FDNPS accident (and at present), by asking them to answer questions about radiation and the Sense of Coherence-13 (SOC-13). We classified the low and high levels of anxiety by asking them to answer questions about radiation, and compared the anxiety-negative (–) group with the anxiety-positive (+) group.

Results

Of the PHNs, 269 (62.6%) were classified in the anxiety (–) group and 161 (37.4%) were in the anxiety (+) group. When the multivariate logistic regression analysis was conducted, the PHNs at the time of the accident (OR: 2.37, p=0.007), current general anxieties about radiation (OR: 3.56, p<0.001), current possession of materials to obtain knowledge about radiation (OR: 2.11, p=0.006) and knowledge of the childhood thyroid cancer increase after the Chernobyl accident (OR: 1.69, p=0.035) were significantly associated with anxiety after the FDNPS accident. The mean SOC-13 was 43.0±7.7, with no significant difference between the anxiety (–) group and anxiety (+) group (p=0.47).

Conclusions

Our study suggested that anxiety about radiation was associated with materials and knowledge about radiation in the PHNs in the Fukushima Prefecture 4 years after the FDNPS accident. It is important for PHNs to obtain knowledge and teaching materials about radiation, and radiation education programmes for PHNs must be established in areas that have nuclear facilities.

To determine what, how, for whom, why, and in what circumstances educational interventions improve the delivery of nutrition care by doctors and other healthcare professionals work.

Design

Realist synthesis following a published protocol and reported following Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. A multidisciplinary team searched MEDLINE, CINAHL, ERIC, EMBASE, PsyINFO, Sociological Abstracts, Web of Science, Google Scholar and Science Direct for published and unpublished (grey) literature. The team identified studies with varied designs; appraised their ability to answer the review question; identified relationships between contexts, mechanisms and outcomes (CMOs); and entered them into a spreadsheet configured for the purpose. The final synthesis identified commonalities across CMO configurations.

Results

Over half of the 46 studies from which we extracted data originated from the USA. Interventions that improved the delivery of nutrition care improved skills and attitudes rather than just knowledge; provided opportunities for superiors to model nutrition care; removed barriers to nutrition care in health systems; provided participants with local, practically relevant tools and messages; and incorporated non-traditional, innovative teaching strategies. Operating in contexts where student and qualified healthcare professionals provided nutrition care in developed and developing countries, these interventions yielded health outcomes by triggering a range of mechanisms, which included feeling competent, feeling confident and comfortable, having greater self-efficacy, being less inhibited by barriers in healthcare systems and feeling that nutrition care was accepted and recognised.

Conclusions

These findings show how important it is to move education for nutrition care beyond the simple acquisition of knowledge. They show how educational interventions embedded within systems of healthcare can improve patients’ health by helping health students and professionals to appreciate the importance of delivering nutrition care and feel competent to deliver it.

The aim was to explore the views of professional stakeholders and healthcare professionals (HCPs) on the linkage of UK National Health Service (NHS) data for paediatric pharmacovigilance purposes and to make recommendations for such a system.

Methods

A mixed methods approach including a literature review, interviews, focus groups and a three-round Delphi survey with HCPs in Scotland was followed by a triangulation process using a systematic protocol. The survey was structured using the Theoretical Domains Framework of behaviour change. Items retained after applying the matrix-based triangulation process were thematically coded. Ethical approval was granted by the North of Scotland Research Ethics Service.

Results

Results from 18 papers, 23 interviewees, 23 participants of focus groups and 61 completed questionnaires in the Delphi survey contributed to the triangulation process. A total of 25 key findings from all four studies were identified during triangulation. There was good convergence; 21 key findings were agreed and remained to inform recommendations. The items were coded as practical/technical (eg, decision about the unique patient identifier to use), mandatory (eg, governed by statute), essential (consistently mentioned in all studies and therefore needed to ensure professional support) or preferable.

Conclusions

The development of a paediatric linked database has support from professional stakeholders and HCPs in Scotland. The triangulation identified three sets of core requirements for a new system of data linkage. An additional fourth set of ‘preferable’ requirements might increase engagement of HCPs and their support for the new system.

The aim of the present study was to assess whether angiography after contrast-enhanced CT (CECT) as per the policy of non-operative management would add to the risk of acute kidney injury in patients with blunt splenic injuries (BSIs).

Design

Cross-sectional study.

Setting

Taiwan.

Participants

Patients with BSI aged >16 years, admitted to a level I trauma centre during the period of January 2004 to December 2014, were retrospectively reviewed. A total of 326 patients with BSI with CECT were included in the study, of whom 100 underwent subsequent angiography and 226 did not.

No significant difference between the patients who underwent angiography and those who did not in terms of the initial haemoglobin (Hb), SCr or estimated glomerular filtration rate (eGFR) level on arrival at the emergency department, 48 hours later, or at discharge. No significant difference in the incidence of CIN was found between these two groups of patients regardless of the criteria for identifying CIN. In the group of patients aged ≥55 years, those who underwent angiography had a significantly worse 48-hour SCr level than those who did not undergo the treatment. In addition, there was no significant difference in the 48-hour SCr level between the two groups of patients when subgrouping the patients according to sex, large haemoperitoneum revealed on CT, systolic blood pressure, initial Hb, initial SCr and initial eGFR levels.

Conclusions

This study demonstrated that angiography does not increase the incidence of CIN, and was not a risk factor to renal function impairment in patients with BSI who had undergone CECT.

Selective participation can bias results in epidemiological surveys. The importance of health status is often suggested as a possible explanation for non-participation but few empirical studies exist. In a population-based study, explicitly focused on sickness absence, health and work, we examined whether a history of high levels of sickness absence was associated with non-participation.

Design

The study is based on data from official sickness absence registers from participants, non-participants and the total target population of the baseline survey of the Health Assets Project (HAP).

Setting

HAP is a population-based cohort study in the Västra Götaland region in South Western Sweden.

Participants

HAP included a random population cohort (n=7984) and 2 cohorts with recent sickness absence (employees (n=6140) and non-employees (n=990)), extracted from the same overall general working-age population.

Primary outcome measures

We examined differences in participation rates between cohorts (2008), and differences in previous sickness absence (2001–2008) between participants (individual-level data) and non-participants or the target population (group-level data) within cohorts.

Results

Participants had statistically significant less registered sickness absence in the past than non-participants and the target population for some, but not all, of the years analysed. Yet these differences were not of substantial size. Other factors than sickness absence were more important in explaining differences in participation, whereby participants were more likely to be women, older, born in Nordic countries, married and have higher incomes than non-participants.

Conclusions

Although specifically addressing sickness absence, having such experience did not add any substantial layer to selective participation in the present survey. Detailed measures are needed to gain a better understanding for health selection in health-related surveys such as those addressing sickness absence, for instance in order to discriminate between selection due to ability or motivation for participation.

Australian opium poppy farms, and facilities for pelletising, manufacturing morphine, and sterilising and packaging bags of morphine.

Main outcome measures

The environmental effects (eg, CO2 equivalent (‘CO2 e’) emissions and water use) of producing 100 mg of morphine. All aspects of morphine production from poppy farming, pelletising, bulk morphine manufacture through to final formulation. Industry-sourced and inventory-sourced databases were used for most inputs.

The environmental effects of growing opium poppies and manufacturing bulk morphine were small. The final stages of morphine production, particularly sterilisation and packaging, contributed to almost 90% of morphine's carbon footprint. Focused measures to improve the energy efficiency and sources for drug sterilisation and packaging could be explored as these are relevant to all drugs. Comparisons of the environmental effects of the production of other drugs and between oral and intravenous preparations are required.

The future of academic medicine is uncertain. Concerns regarding the future availability of qualified and willing trainee clinical academics have been raised worldwide. Of significant concern is our failure to retain postdoctoral trainee clinical academics, who are likely to be our next generation of leaders in scientific discovery.

Objectives

To review the literature about factors that may influence postdoctoral career progression in early career clinical academics.

Design

This study employed a scoping review method. Three reviewers separately assessed whether the articles found fit the inclusion criteria.

Data sources

PubMed, Scopus, Web of Science and Google Scholar (1991–2015).

Article selection

The review encompassed a broad search of English language studies published anytime up to November 2015. All articles were eligible for inclusion, including research papers employing either quantitative or qualitative methods, as well as editorials and other summary articles.

Data extraction

Data extracted from included publications were charted according to author(s), sample population, study design, key findings, country of origin and year of publication.

Results

Our review identified 6 key influences: intrinsic motivation, work–life balance, inclusiveness, work environment, mentorship and availability of funding. It also detected significant gaps within the literature about these influences.

Conclusions

Three key steps are proposed to help support postdoctoral trainee clinical academics. These focus on ensuring that researchers feel encouraged in their workplace, involved in collaborative dialogue with key stakeholders and able to access reliable information regarding their chosen career pathway. Finally, we highlight recommendations for future research.

This study had a case–control design nested within a cohort of 1 million people from the general population, which was followed from 2005 to 2010. The odds of prior clinical visits for DHSs, namely carpal tunnel syndrome (CTS), flexor tenosynovitis, limited joint mobility and Dupuytren's disease, were estimated for cases and controls. We used a conditional logistic regression model to estimate the OR and 95% CI of T2DM in association with a history of DHSs. The validity and predictive value of using the history of DHSs in predicting T2DM diagnosis were calculated.

Setting

Taiwan National Health Insurance medical claims.

Participants

We identified 33 571 patients receiving a new diagnosis of T2DM (cases) between 2005 and 2010. Each T2DM case was matched with 5 controls who had the same sex and birth year and were alive on the date of T2DM diagnosis.

Primary and secondary outcome measures

The primary outcome measure was T2DM diagnosis.

Results

The OR of T2DM in association with prior clinical visits was significantly increased for overall DHS and CTS, being 1.15 (95% CI 1.10 to 1.20) and 1.22 (95% CI 1.16 to 1.29), respectively. Moreover, 11% of patients with T2DM made clinical visits for CTS within 3 months prior to T2DM diagnosis. The history of DHSs had low sensitivity (<0.1% to 5.2%) and a positive predictive value (9.9% to 11.7%) in predicting T2DM.

Conclusions

Despite the unsatisfactory validity and performance of DHSs as a clinical tool for detecting patients with undiagnosed T2DM, this study provided evidence that clinical visits for DHSs, particularly for CTS, can be a sign of undiagnosed T2DM.

To demonstrate the costs, outcomes and economic impact of early intervention in psychosis (EIP) services.

Design

Longitudinal retrospective observational study of service usage and outcome data from mental health and acute care services for all those with a diagnosis of psychosis in contact with mental health services over a 3-year period (April 2010–March 2013).

Change in housing status, change in employment status and improvement on each of the four domains of the Health of the Nation Outcome Scale (HONOS) questionnaire. Costs of mental and acute health inpatient, outpatient and community service use were also included in the study.

Results

Patients in EIP services were 116% more likely (95% CI 1.263 to 3.708) to gain employment, 52% more likely to become accommodated in a mainstream house (95% CI 0.988 to 2.326) and 17% more likely to have an improvement in the emotional well-being domain of the HONOS questionnaire (95% CI 1.067 to 1.285), as compared to those in non-EIP services. Annual National Health Service (NHS) costs were also significantly lower for patients using EIP services compared to non-users. The mean annual NHS cost savings associated with EIP were £4031 (95% CI £1281 to £6780). These mostly came from lower mental health inpatient costs (£4075, 95% CI £1164 to £6986), lower acute hospital outpatient costs (£59, 95% CI £9 to £109), lower accident and emergency costs (£31, 95% CI £12 to £51), and higher mental health community costs (£648, 95% CI £122 to £1175). If all people with a first-episode psychosis across England were to be treated by EIP services, the savings in societal costs would be an estimated £63.3 million per year, of which £33.5 million would be in NHS costs.

Conclusions

Treatment within an EIP service is associated with better health and social outcomes, and reduced costs.

The majority of mothers do not correctly identify their child's weight status. The reasons for the misperception are not well understood. This study's objective was to describe maternal perceptions of their child's body mass index (BMI) and maternal report of weight concerns raised by a health professional.

Design

Prospective, community-based cohort.

Participants

Data were collected in 2010 from 450 mothers previously included in a longitudinal birth cohort. Mothers of children aged 6–8 years reported their child's anthropometric measures and were surveyed concerning their opinion about their child's weight. They were also asked if a healthcare provider raised any concerns regarding their child's body weight. Child BMI was categorised according to the WHO Growth Charts adapted for Canada. Descriptive statistics and bivariate analyses were used to evaluate mothers' ability to correctly identify their children's body habitus.

Results

74% of children had a healthy BMI, 10% were underweight, 9% were overweight and 7% were obese. 80%, 89% and 62% of mothers with underweight, overweight and obese children, respectively, believed that their child was at the right weight. The proportion of mothers who recalled a health professional raising concerns about their child being underweight, overweight, and obese was low (12.5%).

Conclusions

The majority of mothers with children at unhealthy weights misclassified and normalised their child's weight status, and they did not recall a health professional raising concerns regarding their child's weight. The highest rates of child body weight misclassification occurred in overweight children. This suggests that there are missed opportunities for healthcare professionals to improve knowledge exchange and early interventions to assist parents to recognise and support healthy weights for their children.

The study aimed to establish current levels of overseas volunteering and placement activity across all staff grades within the National Health Service (NHS) in the North West of England.

Design

Cross-sectional survey.

Instrument

Descriptive statistics.

Setting

4 main regional hospitals in the North West of England, and additional NHS staff training events.

Participants

Convenience sample of NHS staff (n=911).

Results

911 NHS staff took part in the survey. The medical and dental staff group returned the highest number of responses (32.1%). 42% of staff reported some form of overseas volunteering or placement experience. Most staff took an international placement as students (33.6% men; 40.6% women). Medium-term placements were undertaken by 46.7% of men, and 52.5% of women. Settlement stays (ie, over 1 year) were reported by 7.6% men, and 8.3% women). The majority of respondents engaged in international placement were from the age groups incorporating ‘below 25’ to ‘41–50’ (74%). Multiple placement experiences were uncommon: 2.5% of respondents reported three periods of overseas activity, and 1.5% reported four. All those with multiple placement experience came from the staff groups incorporating midwife/nurse/health visitor, and medical and dental.

Conclusions

This survey captured a snapshot of current levels of volunteering and overseas placement activity across NHS staff grades in the North West. Owing to relatively homogenous organisational structures, findings are likely to broadly represent the position across the organisation as a whole. Although some degree of overseas placement activity is undertaken by a relatively high proportion of NHS staff, such activity is currently heavily skewed towards higher clinical staff grades. Significant numbers of allied health professionals and equivalent non-clinical cadres also report overseas experience, and we anticipate that the numbers will continue to rise if current policy initiatives gain momentum.

Case reports of capecitabine cardiotoxicity resemble those seen with intravenous 5-fluorouracil (5-FU) with chest pain as the predominant manifestation, but few studies of capecitabine cardiotoxicity are available. We aimed to determine the incidence of symptomatic cardiotoxicity from capecitabine in patients with breast cancer and to identify risk factors.

Methods

We reviewed medical records of consecutive women with breast cancer treated with capecitabine (1000 mg/m2 two times per day) from 2002 to 2012 at one institution.

The incidence of cardiotoxicity from capecitabine resembles that of intravenous 5-FU (5%). Cardiac comorbidity, hypercholesterolaemia and current smoking were associated with development of cardiotoxicity.

The Fukushima Daiichi Nuclear Power Plant accident, which occurred after the Great East Japan Earthquake and Tsunami in March 2011, may have a considerable long-term impact on the lives of area residents. The aims of this study were to determine the trajectories of psychological distress using 3-year consecutive data, and to find predictive factors of severe distress that may also prove useful for public health intervention.

Methods

Data were obtained on 12 371 residents who were registered in the municipalities categorised as complete evacuation areas for 3 years after the disaster and who completed an assessment in each of the 3 years.

Results

Using group-based trajectory modelling, we identified four trajectory patterns distinguished by the levels of psychological distress, which gradually improved over time in all trajectories. Subjective sleep insufficiency, problem drinking, poor social support and perception of radiation risk 3 years after the accident were associated with the severity of psychological distress, according to the multivariate analysis.

Conclusions

The identified factors may be useful for community-based mental healthcare over the long term following a nuclear disaster.

In the UK, 1 in 10 babies require specialist neonatal care. This care can last from hours to months depending on the need of the baby. The increasing survival of very preterm babies has increased neonatal care resource use. Evidence from multiple studies is crucial to identify factors which may be important for predicting length of stay (LOS). The ability to predict LOS is vital for resource planning, decision-making and parent counselling. The objective of this review was to identify which factors are important to consider when predicting LOS in the neonatal unit.

Design

A systematic review was undertaken which searched MEDLINE, EMBASE and Scopus for papers from 1994 to 2016 (May) for research investigating prediction of neonatal LOS. Strict inclusion and exclusion criteria were applied. Quality of each study was discussed, but not used as a reason for exclusion from the review.

Main outcome measure

Prediction of LOS in the neonatal unit.

Results

9 studies were identified which investigated the prediction of neonatal LOS indicating a lack of evidence in the area. Inherent factors, particularly birth weight, sex and gestational age allow for a simple and objective prediction of LOS, which can be calculated on the first day of life. However, other early occurring factors may well also be important and estimates may need revising throughout the baby's stay in hospital.

Conclusions

Predicting LOS is vital to aid the commissioning of services and to help clinicians in their counselling of parents. The lack of evidence in this area indicates a need for larger studies to investigate methods of accurately predicting LOS.

Leptin is a pleiotropic hormone associated with learning and memory via brain receptors. However, elevated plasma leptin levels may impair cognitive and memory functions. Since individual differences in memory performance affect students’ ability to learn, we aimed to study the relation between leptin status in adolescence and school performance.

Design and setting

We studied 568 adolescents aged 16–17 years from Santiago. A cross-sectional analysis was carried out on a birth cohort conducted in Santiago (Chile).

Primary and secondary outcome measures

We measured serum leptin concentration using an enzyme-linked immunosorbent assay. Cut-offs from the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) Study for 16-year-olds were used to define abnormally high leptin levels (hyperleptinaemia). Academic performance was measured using high-school grades and grade point average (GPA). Data were collected in 2009–2012; data analysis was performed in 2014.

Results

15% of participants had hyperleptinaemia. They had significantly lower school grades and GPA compared with participants with normal leptin levels (eg, GPA mean difference=33.8 points). Leptin levels were negative and significantly correlated with school grades in 9th, 10th and 12th. Similarly, it was negatively correlated with high-school GPA. After controlling for health, sociodemographic and education confounders, the chances of having a performance ≥75th centile in students having hyperleptinaemia were 32% (95% CI 0.19% to 0.89%) that of students having normal serum leptin concentration.

Conclusions

In high school students, abnormally high levels of leptin were associated with poorer academic performance. These findings support the idea of a relationship between leptin and cognition. Further research is needed on the cognitive effects of leptin in younger populations.

To analyse the effect of women's characteristics on their willingness to join a blind or a non-blind subtrial or to be excluded by physicians.

Design

Primary prevention trial of postmenopausal hormone therapy (HT). A 2x2, randomised design with a non-blind HT arm or control arm and a blind HT arm or placebo arm.

Setting

3 clinical centres in Estonia.

Methods

Interest in joining the trial was asked in a questionnaire together with demographic and health status data. Interested and eligible women were invited to a health examination that also informed whether they belonged to a blind or to a non-blind subtrial; the arm was not revealed. Trial physicians made further exclusions when checking the women's eligibility. Thereafter, informed consent was asked as detailed in the flow chart. Comparisons were made between non-blind and blind subtrials. Analyses were carried out for each of the background variables.

Outcome measures

The proportion of willingness, eligibility and attendance.

Results

Women randomised to the non-blind subtrial were more willing to join (relative risk (RR) 1.17) and more likely to be found eligible by physicians (RR 1.10) than women in the blind subtrial, resulting in larger attendance (RR 1.29). Women with higher education were differentially more willing to join the non-blind trial (RR 1.29) than those with basic education (RR 1.08); the differential willingness of never-smokers (RR 1.20) was larger than that of current smokers (RR 1.07). The differential exclusion by physicians by education and smoking were small. Some subjective symptoms (eg, diarrhoea/constipation, stomach pain) had reverse differential effects on attendance in the non-blind subtrial in comparison to the blind subtrial. Menopausal symptoms did not affect the differential interest, eligibility or attendance.

Conclusions

Blinding in RCT reduces attendance, due to decisions of the women and the trial physicians. Differential attendance by blinding may affect the generalisability of the results from trials.

Patients with cancer frequently require unplanned admission to the intensive care unit (ICU). Our objectives were to assess hospital and 180-day mortality in patients with a non-haematological malignancy and unplanned ICU admission and to identify which factors present on admission were the best predictors of mortality.

Design

Retrospective review of all patients with a diagnosis of solid tumours following unplanned admission to the ICU between 1 August 2008 and 31 July 2012.

Short-term and medium-term survival in patients with solid tumours admitted to ICU is better than previously reported, suggesting that the presence of cancer alone should not be a barrier to ICU admission.

The aim of the study was to evaluate awareness of the varicella zoster virus and the acceptability of the newly available herpes zoster (HZ) vaccine in the over 50 years old general population.

Design

The research was observational.

Setting

The study was carried out in Ferrara by administering a questionnaire to patients of the Local Health Authority (LHA), general practitioners (GPs) and Public Health Department outpatient clinics.

Participants

The questionnaire was completed by 1001 residents of Ferrara Province.

Results

Of the respondents, 98% and 95% (57% female) were aware of varicella and HZ, respectively, but 91% were unaware of the HZ vaccine. Nevertheless, 58% declared that they were in favour of vaccination in this regard, and the acceptability of the vaccine was positively affected by: age (p=0.005); knowing someone who had suffered from HZ (p=0.05); being in favour of vaccination in general (p<0.0001); receiving advice to do so from their GP (p<0.0001) and willingness to get vaccinated even on a fee-paying basis (p<0.0001). Indeed, most (73%) respondents were willing to pay to get vaccinated, indicating an ideal cost of 50. Higher education (p=0.04), being in favour of vaccinations in general (p<0.0001) and GP advice (p<0.0001) positively affected this choice. Furthermore, 61% of the participants initially unfavourable (p<0.0001) to this immunisation would change their decision not to vaccinate thanks to their GP's advice.

Conclusions

This study assessed the level of awareness and the attitudes of the population aged over 50 years, highlighting aspects to be focused on in the promotion of the HZ vaccine.

We examine interactions among 3 factors that affect patient waits and use of overtime in outpatient clinics: clinic congestion, patient punctuality and physician processing rates. We hypothesise that the first 2 factors affect physician processing rates, and this adaptive physician behaviour serves to reduce waiting times and the use of overtime.

Appointment times, patient arrival times, start of service and physician processing times were collected for 105 visits at a low-volume suburban clinic 1, 264 visits at a medium-volume academic clinic 2 and 22 266 visits at a high-volume academic clinic 3 over 3 distinct spans of time.

Intervention

Data from the first clinic were previously used to document an intervention to influence patient punctuality. This included a policy that tardy patients were rescheduled.

Primary and secondary outcome measures

Clinicians' processing times were gathered, conditioned on whether the patient or clinician was tardy to test the first hypothesis. Probability distributions of patient unpunctuality were developed preintervention and postintervention for the clinic in which the intervention took place and these data were used to seed a discrete-event simulation.

Results

Average physician processing times differ conditioned on tardiness at clinic 1 with p=0.03, at clinic 2 with p=10–5 and at clinic 3 with p=10–7. Within the simulation, the adaptive physician behaviour degrades system performance by increasing waiting times, probability of overtime and the average amount of overtime used. Each of these changes is significant at the p<0.01 level.

Conclusions

Processing times differed for patients in different states in all 3 settings studied. When present, this can be verified using data commonly collected. Ignoring these behaviours leads to faulty conclusions about the efficacy of efforts to improve clinic flow.

To investigate the relationship between the occurrence of stress fracture and premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) in Japanese adolescent athletes.

Design

Cross-sectional study.

Setting

Osaka, Japan.

Participants

A school-based survey on menstruation and school life was conducted using a sample of 1818 Japanese female students who belonged to two public high schools in Japan. Among them, we recruited 394 athletes who had regular menstrual cycles (25–38 days) and completed a questionnaire about their premenstrual symptoms and their competitive career.

Main outcome measure

Premenstrual symptoms and the occurrence of stress fracture.

Results

The prevalences of moderate-to-severe PMS and PMDD were 8.9% and 1.3%, respectively, which were the same as in collegiate athletes in a previous study. Premenstrual symptoms disturbed ‘Work efficiency or productivity, home responsibilities’, ‘Relationships with coworkers or family’ and ‘Athletic performance in training or competition’ more severely than menstrual pain (p=0.031, p=0.004 and p<0.001, respectively). 66 athletes (16.8%) reported having experienced a stress fracture. The severity of ‘Overeating or food cravings’, ‘Physical symptoms’ and ‘Performance in training or competition’ in athletes with previous stress fractures were much higher than in those without a history of stress fractures (p=0.015, p=0.008 and p=0.006, respectively). In terms of premenstrual symptoms, ‘Physical symptoms’ was associated with an increased risk of stress fractures in athletes (OR 1.66, 95% CI 1.06 to 2.62).

Conclusions

The results from this study indicated that premenstrual symptoms may affect athletic performance and has the risk of stress fractures in adolescent athletes.

Time series models are effective tools for disease forecasting. This study aims to explore the time series behaviour of 11 notifiable diseases in China and to predict their incidence through effective models.

Settings and participants

The Chinese Ministry of Health started to publish class C notifiable diseases in 2009. The monthly reported case time series of 11 infectious diseases from the surveillance system between 2009 and 2014 was collected.

Methods

We performed a descriptive and a time series study using the surveillance data. Decomposition methods were used to explore (1) their seasonality expressed in the form of seasonal indices and (2) their long-term trend in the form of a linear regression model. Autoregressive integrated moving average (ARIMA) models have been established for each disease.

Results

The number of cases and deaths caused by hand, foot and mouth disease ranks number 1 among the detected diseases. It occurred most often in May and July and increased, on average, by 0.14126/100 000 per month. The remaining incidence models show good fit except the influenza and hydatid disease models. Both the hydatid disease and influenza series become white noise after differencing, so no available ARIMA model can be fitted for these two diseases.

Conclusion

Time series analysis of effective surveillance time series is useful for better understanding the occurrence of the 11 types of infectious disease.

Evidence on the association between herpes simplex virus (HSV) and excessive adiposity, such as obesity (body mass index ≥30 kg/m2) and abdominal obesity (waist circumference (WC) >102 or 88 cm), has been inconsistent. We sought to examine whether age–period–cohort (APC) effects could explain for the observed heterogeneities.

Design

Population-based cross-sectional study.

Participants

Adults aged 20–49 years with available serological data in the National Health and Nutrition Examination Survey (NHANES) in 1999–2012.

Exposure measures

Obesity and abdominal obesity.

Results

In men, excessive adiposity was generally not associated with HSV1 or HSV2 (all p>0.05); however, there were positive correlations between HSV seroprevalence and excessive adiposity in certain age and birth cohort groups. Based on APC analysis, abdominally obese men aged 30–40 years showed a nearly 20% increase in risk for HSV1 seropositivity (adjusted prevalence ratio (aPR)=1.18; 95% CI 1.10 to 1.27) as compared with abdominally non-obese men of the same age; there was no such association in men of other age groups. Also, men of a large WC who were born before 1962 or after 1979 had a 28% higher risk for HSV2 seropositivity than those of a normal WC in the same birth cohorts (aPR=1.28, 95% CI 1.17 to 1.54); yet the association did not hold for men in other cohorts (aPR=0.86, 95% CI 0.64 to 1.17). In women, a large WC was correlated with a minimally increased HSV1 seroprevalence (aPR=1.07, 95% CI 1.01 to 1.13) but not with HSV2 seropositivity (aPR=1.13; 95% CI 0.99 to 1.28). Likewise, there were strong associations between abdominal obesity and HSV2 seropositivity in subgroups of women participating in the earliest survey cycle (aPR=1.41, 95% CI 1.12 to 1.78) but not in other survey periods (aPR=0.94, 95% CI 0.85 to 1.03).

Conclusions

There was no consistent evidence for strong associations between HSV seropositivity and excessive adiposity in adults. APC analysis results further cautioned the generalisability of previous reports based on 1 or 2 cycles of survey data.

To explore the perceived acceptability, advantages and disadvantages of electronic multicompartment medication devices.

Design

Qualitative study using 8 focus groups and 10 individual semistructured interviews. Recordings were transcribed and analysed thematically. Strategies were employed to ensure the findings were credible and trustworthy.

Participants and setting

Community pharmacists (n=11), general practitioners (n=9), community nurses (n=12) and social care managers (n=8) were recruited from the National Health Service (NHS) and local authority services. Patients (n=15) who were current conventional or electronic multicompartment medication device users or had medication adherence problems were recruited from community pharmacies. 3 informal carers participated.

Results

Electronic multicompartment medication devices which prompt the patient to take medication may be beneficial for selected individuals, particularly those with cognitive impairment, but who are not seriously impaired, provided they have a good level of dexterity. They may also assist individuals where it is important that medication is taken at fixed time intervals. These are likely to be people who are being supported to live alone. No single device suited everybody; smaller/lighter devices were preferred but their usefulness was limited by the small number/size of storage compartments. Removing medications was often challenging. Transportability was an important factor for patients and carers. A carer's alert if medication is not taken was problematic with multiple barriers to implementation and no consensus as to who should receive the alert. There was a lack of enthusiasm among professionals, particularly among pharmacists, due to concerns about responsibility and funding for devices as well as ensuring devices met regulatory standards for storage and labelling.

Conclusions

This study provides indicators of which patients might benefit from an electronic multicompartment medication device as well as the kinds of features to consider when matching a patient with a device. It also highlights other considerations for successful implementation including issues of responsibility, regulation and funding.

To measure the effect of an urgent care telephone service NHS 111 on population perceptions of urgent care.

Design

Controlled before and after population survey, using quota sampling to identify 2000 respondents reflective of the age/sex profile of the general population.

Setting

England. 4 areas where NHS 111 was introduced, and 3 control areas where NHS 111 had yet to be introduced.

Participants

28 071 members of the general population, including 2237 recent users of urgent care.

Intervention

NHS 111 offers advice to members of the general population seeking urgent care, recommending the best service to use or self-management. Policymakers introduced NHS 111 to improve access to urgent care.

Outcomes measures

The primary outcome was change in satisfaction with recent urgent care use 9 months after the launch of NHS 111. Secondary outcomes were change in satisfaction with urgent care generally and with the national health service.

Results

The overall response rate was 28% (28 071/100 408). 8% (2237/28 071) had used urgent care in the previous 3 months. Of the 652 recent users of urgent care in the NHS 111 intervention areas, 9% (60/652) reported calling NHS 111 in the ‘after’ period. There was no evidence that the introduction of NHS 111 was associated with a changed perception of recent urgent care. For example, the percentage rating their experience as excellent remained at 43% (OR 0.97, 95% CI 0.69 to 1.37). Similarly, there was no change in population perceptions of urgent care generally (1.06, 95% CI 0.95 to 1.17) or the NHS (0.94, 95% CI 0.85 to 1.05) following the introduction of NHS 111.

Conclusions

A new telephone triage service did not improve perceptions of urgent care or the health service. This could be explained by the small amount of NHS 111 activity in a large emergency and urgent care system.

To identify patient's views on the functionality required for personalised access to the secondary care electronic health record (EHR) and their priorities for development.

Design

Quantitative analysis of a cross-sectional self-complete survey of patient views on required EHR functionality from a secondary care EHR, including a patient ranking of functionality.

Setting

Secondary care patients attending a regional cystic fibrosis unit in the north of England.

Participants

201 adults (106 (52.7%) males), median age 29 years (range 17–58 years), entered and completed the study. Inclusion criteria are as follows: a confirmed diagnosis of cystic fibrosis, aged 16 years and over, at the time of clinical stability.

Outcome measures

Quantitative responses within 4 themes; (1) value placed on aspects of the EHR; (2) access requirements to functions of the EHR; (3) views on information sent to the EHR and (4) patient feedback entered into the EHR. A ranked score for 15 functions of the EHR was obtained.

Results

Highest ratings (% reporting item as very important/important) were reported for access to clinical measures (lung function (94%), C reactive protein (84%), sputum microbiology (81%) and blood results (80%)), medication changes (82%) and lists (83%) and sending repeat prescription (83%) and treatment requests (80%), while sending symptom diaries was less so (62%). Email contact with clinicians was the most valuable communication element of the EHR (84% very important/important). Of 15 features of the EHR (1=most desirable to 15=least desirable), patients identified ‘clinical measures’ (2.62 (CI 2.07 to 3.06)), and ‘access to medication lists’ (4.91 (CI 4.47 to 5.44)), as highest priority for development and the ability to comment on errors/omissions (11.0 (CI 10.6 to 11.5)) or experience of care (11.8 (CI 11.4 to 12.2)) as lowest.

Conclusions

Patients want extensive personal access to their hospital EHR, placing high importance on the viewing of practical clinical measures and medication management. These influence routine day-to-day care and are priorities for development.

To assess the clinical status of chronic spontaneous urticaria (CSU) and understand treatment approaches in Italy through specialists who treat CSU (dermatologists and allergy specialists) and CSU patients' experience.

Design

Multicentre survey.

Setting

Online structured questionnaires (one for physicians and one for patients).

Participants

Physicians and patients with CSU in Italy.

Interventions

None.

Primary/secondary outcomes

Physician and patient attitudes/experiences.

Results

Survey results from 160 allergy and 160 dermatology specialists show that specialists see a median of 40 (IQR 20–80) patients with CSU/year. While most specialists (56%) know the CSU guidelines, only 27% use them regularly (36% of allergy specialists vs 18% of dermatologists). This is reflected in treatment choices with differences between physicians who use guidelines regularly and those who do not: 91.6% vs 71.7% choose standard-dose, non-sedating antihistamines as first-line treatment; 85.9% vs 56.0% select up-dosing for second-line treatment and 65.3% vs 37.2% add leukotriene receptor antagonists or H2-antihistamines as third-line treatment. The diaries from 1385 patients highlight that, regardless of treatment regimen, 29.4% of currently treated patients are refractory to therapy. Specialists aim to resolve symptoms and only 7.8% report improving quality of life (QoL) as a priority. Only 16.6% of specialists are familiar with and use the Urticaria Activity Score while 46.9% do not know it. Overall, 537 patients with CSU were surveyed (median age 37 years, IQR 30–46; 44.3% men; median disease duration 5 years, IQR 3–20). Approximately 62% confirm that CSU negatively impacts their QoL. Patients also complain of difficulties in getting information and support: <5% of medical centres provide patient support services.

Conclusions

In Italy, the gap between guideline-based care and QoL-related needs in CSU patients affects treatment satisfaction. This information could be used to improve the management of CSU in Italy.

There have been conflicting data suggesting that prenatal mercury exposure is associated with adverse cardiovascular measures in children. We therefore analysed a large prospective population study to investigate whether prenatal mercury exposure might influence offspring blood pressure (BP) and heart rate adversely.

Design

Prospective birth cohort.

Setting

The Avon Longitudinal Study of Parents and Children (ALSPAC).

Participants

Maternal whole blood collected in the first half of pregnancy was assayed for mercury and selenium. The offspring were followed throughout childhood and adolescence.

Outcome measures

Offspring resting BP and heart rates measured under standard conditions on six occasions between ages 7 and 17 years (numbers analysed: 1754 at 7 years to 1102 at 17).

Results

Statistical analyses took account of various factors present in pregnancy, including family adversity, maternal age, parity, smoking and alcohol intake. Unadjusted and adjusted regression analyses assessed the relationship between maternal prenatal mercury levels and offspring resting systolic and diastolic BP, and heart rates. A final set of analyses took account of selenium. Each analysis was carried out for all offspring, those whose mothers had, and those that had not, consumed fish during pregnancy. Further analysis for all offspring ascertained whether there were significant interaction effects between the sexes. There was little evidence to suggest that prenatal mercury exposure resulted in a clinically important increase in offspring BP in the whole group, since no effect size for an increase of 1 SD of blood mercury level was >0.3 mm Hg. Only 1 association was significant at p<0.05 and therefore likely due to chance.

Conclusions

This study reveals no evidence to support the hypothesis that prenatal mercury exposure has adverse long-term effects on offspring BP or heart rates during childhood or adolescence.

The STarT Back Tool has good predictive performance for non-specific low back pain in primary care. We therefore aimed to investigate whether a modified STarT Back Tool predicted outcome with a broader group of musculoskeletal patients, and assessed the consequences of using existing risk-group cut-points across different pain regions.

In PhysioDirect and SAMBA, poor 6-month physical health was 18.5% and 28.2%, respectively. Modified STarT Back Tool score AUCs for predicting outcome in back pain were 0.72 and 0.79, neck 0.82 and 0.88, upper limb 0.79 and 0.86, lower limb 0.77 and 0.83, and multisite pain 0.83 and 0.82 in PhysioDirect and SAMBA, respectively. Differences between pain region AUCs were non-significant. Optimal cut-points to discriminate low-risk and medium-risk/high-risk groups depended on pain region and clinical services.

Conclusions

A modified STarT Back Tool similarly predicts 6-month physical health outcome across 5 musculoskeletal pain regions. However, the use of consistent risk-group cut-points was not possible and resulted in poor sensitivity (too many with long-term disability being missed) or specificity (too many with good outcome inaccurately classified as ‘at risk’) for some pain regions. The draft tool is now being refined and validated within a new programme of research for a broader musculoskeletal population.

To evaluate an electronic patient referral system from one UK hospital Trust to community pharmacies across the North East of England.

Setting

Two hospital sites in Newcastle-upon-Tyne and 207 community pharmacies.

Participants

Inpatients who were considered to benefit from on-going support and continuity of care after leaving hospital.

Intervention

Electronic transmission of an information related to patient's medicines to their nominated community pharmacy. Community pharmacists to provide a follow-up consultation tailored to the individual patient needs.

Primary and secondary outcomes

Number of referrals made to and received by different types of pharmacies; reasons for referrals; accepted/completed and rejected referred rates; reasons for rejections by community pharmacists; time to action referrals; details of the follow-up consultations; readmission rates at 30, 60 and 90 days post referral and number of hospital bed days.

Results

2029 inpatients were referred over a 13-month period (1 July 2014–31 July 2015). Only 31% (n=619) of these patients participated in a follow-up consultation; 47% (n=955) of referrals were rejected by community pharmacies with the most common reason being ‘patient was uncontactable’ (35%, n=138). Most referrals were accepted/completed within 7 days of receipt and most rejections were made >2 weeks after referral receipt. Most referred patients were over 60 years of age and referred for a Medicines Use Review (MUR) or enrolment for the New Medicines Service (NMS). Those patients who received a community pharmacist follow-up consultation had statistically significant lower rates of readmissions and shorter hospital stays than those patients without a follow-up consultation.

Conclusions

Hospital pharmacy staff were able to use an information technology (IT) platform to improve the coordination of care for patients transitioning back home from hospital. Community pharmacists were able to contact the majority of patients and results indicate that patients receiving a follow-up consultation may have lower rates of readmission and shorter hospital stays.

This study aimed to examine the association of eczema, asthma and hay fever with mental health in a general child population and to assess the influence of parental socioeconomic position on these associations.

Methods

We conducted a cross-sectional health survey of children aged 3, 6, 11 and 15 years in the City of Copenhagen, Denmark. Individual questionnaire data on eczema, asthma, and hay fever and mental health problems assessed using the Strengths and Difficulties Questionnaire (SDQ) was linked to register data on demographics and parental socioeconomic position. 9215 (47.9%) children were included in the analyses.

Results

Linear regression analyses showed that children with current eczema symptoms had higher SDQ scores (mean difference, 95% CI) of emotional problems (0.26, 0.12 to 0.39), conduct problems (0.19, 0.09 to 0.29) and hyperactivity problems (0.32, 0.16 to 0.48); children with current asthma symptoms had higher SDQ scores of emotional problems (0.45, 0.32 to 0.58), conduct problems (0.28, 0.18 to 0.38) and hyperactivity problems (0.52, 0.35 to 0.69); and children with current hay fever symptoms had higher SDQ scores of emotional problems (0.57, 0.42 to 0.72), conduct problems (0.22, 0.11 to 0.33), hyperactivity problems (0.44, 0.26 to 0.61) and peer problems (0.14, 0.01 to 0.26), compared with children without current symptoms of the relevant disease. For most associations, parental socioeconomic position did not modify the effect.

Conclusions

Children with eczema, asthma or hay fever had more emotional, conduct and hyperactivity problems, but not peer problems, compared with children without these diseases. Atopic diseases added equally to the burden of mental health problems independent of socioeconomic position.

To evaluate the impact of comorbidities, acute illness burden and social determinants of health on predicting the risk of frequent hospital admissions.

Design

Multivariable logistic regression was used to associate the predictive variables extracted from electronic health records and frequent hospital admission risk. The model's performance of our predictive model was evaluated using a 10-fold cross-validation.

Setting

A single tertiary hospital in Singapore.

Participants

All adult patients admitted to the hospital between 1 January 2013 and 31 May 2014 (n=25 244).

Main outcome measure

Frequent hospital admissions, defined as 3 or more inpatient admissions within 12 months of discharge. Area under the receiver operating characteristic curve (AUC) of the predictive model, and the sensitivity, specificity and positive predictive values for various cut-offs.

Results

4322 patients (17.1%) met the primary outcome. 11 variables were observed as significant predictors and included in the final regression model. The strongest independent predictor was treatment with antidepressants in the past 1 year (adjusted OR 2.51, 95% CI 2.26 to 2.78). Other notable predictors include requiring dialysis and treatment with intravenous furosemide during the index admission. The predictive model achieved an AUC of 0.84 (95% CI 0.83 to 0.85) for predicting frequent hospital admission risk, with a sensitivity of 73.9% (95% CI 72.6% to 75.2%), specificity of 79.1% (78.5% to 79.6%) and positive predictive value of 42.2% (95% CI 41.1% to 43.3%) at the cut-off of 0.235.

Conclusions

We have identified several predictors for assessing the risk of frequent hospital admissions that achieved high discriminative model performance. Further research is necessary using an external validation cohort.

To identify underlying causes for failure of medical thesis projects and the constantly high drop-out rate in Germany from the supervisors' perspective and to compare the results with the students' perspective.

Setting

Cross-sectional survey. Online questionnaire for survey of medical thesis supervisors among the staff of Charité—Universitätsmedizin Berlin, Germany. Published, earlier longitudinal survey among students for comparison.

Participants

1069 thesis supervisors participated.

Data extraction and synthesis

Data are presented using descriptive statistics, and the 2 test served to compare the results among supervisors with the earlier data from the longitudinal survey of doctoral students.

Primary and secondary outcomes

Not applicable. This survey is an observational study.

Results

Of 3653 potential participants, 1069 (29.3%) supervising 3744 doctoral candidates participated in the study. Supervisors considered themselves to be highly motivated and to offer adequate supervision. On the other hand, 87% stated that they did not feel well prepared for thesis supervision. Supervisors gave lack of timeliness of doctoral students and personal differences (p=0.024 and p=0.001) as the main reasons for terminating thesis projects. Doctoral students predominantly mentioned methodological problems and difficult subjects as critical issues (p=0.001 and p<0.001). Specifically, students felt ill prepared for the statistical part of their research—49.5% stated that they never received statistical assistance, whereas 97% of supervisors claimed to help their students with statistical analysis.

Conclusions

The authors found that both thesis supervisors and medical students feel ill prepared for their roles in the process of a medical dissertation. Contradictory reasons for terminating medical thesis projects based on supervisors' and students' self-assessment suggest a lack of communication and true scientific collaboration between supervisors and doctoral students as the major underlying issue that requires resolution.

Increased rates of illicit drug inhalation are thought to expose opiate misusers (OMUs) to an enhanced risk of respiratory health problems. This pilot study aimed to determine the feasibility of undertaking respiratory screening of OMUs in a community clinic.

Setting

Single-centre UK community substance misuse clinic.

Participants

All clinic attendees receiving treatment for opiate misuse were eligible to participate. 36 participants (mean age=37) were recruited over a 5-week period. The sample included 26 males and 10 females.

Outcome measures

Spirometry without bronchodilation; health related quality of life EQ-5D-3L; Asthma Control Test; Mini Asthma Quality of Life; Clinical COPD Questionnaire and the Treatment Outcome Profile were used to assess the respiratory health of participants. Findings were discussed with staff and service users in 2 patient and public involvement events and feedback was analysed thematically.

Results

34 participants reported that they had smoked heroin. 8 participants diagnosed with asthma, scored under 13 on the Asthma Control Test, suggesting poorly controlled asthma. Participants (n=28), without a diagnosis of asthma completed the Lung Function Questionnaire. Of these, 79% produced scores under 18, indicating symptoms associated with the development of chronic obstructive pulmonary disease. Spirometry showed 14% of all participants had forced expiratory volume in 1 s/forced vital capacity <0.7 (without bronchodilator), indicating potential obstructive lung disease. Feedback from service users and staff suggested a willingness and capacity to deliver respiratory health screening programmes. Insight towards the difficulties service users have in accessing services and the burden of respiratory health was also provided.

Conclusions

It is feasible to undertake respiratory health screening of OMUs in a community clinic. Larger screening studies are warranted to determine the prevalence of respiratory health problems in this population. Research regarding asthma medicines adherence and access to healthcare among OMUs is also required.

We seek to address gaps in knowledge and agreement around optimal frailty assessment in the acute medical care setting. Frailty is a common term describing older persons who are at increased risk of developing multimorbidity, disability, institutionalisation and death. Consensus has not been reached on the practical implementation of this concept to assess clinically and manage older persons in the acute care setting.

A panel of national experts (academics, front-line clinicians and specialist charities) were invited to electronic correspondence.

Results

Variables reflecting accumulated deficit and high resource usage were perceived by participants as the most useful indicators of frailty in the acute care setting. The Acute Medical Unit and Care of the older Persons Ward were perceived as optimum settings for frailty assessment. ‘Clinically meaningful and relevant’, ‘simple (easy to use)’ and ‘accessible by multidisciplinary team’ were perceived as characteristics of a successful frailty assessment tool in the acute care setting. No agreement was reached on optimal timing, number of variables and organisational structures.

Conclusions

This study is a first step in developing consensus for a clinically relevant frailty assessment model for the acute care setting, providing content validation and illuminating contextual requirements. Testing on clinical data sets is a research priority.

Percentages of research articles that indicated the availability of their raw data sets in their data sharing statements, and those that easily made their data sets available on request.

Results

3 articles contained the data in the article. 50 out of 157 (32%) remaining articles indicated the availability of their data sets. 12 used publicly available data and the remaining 38 were sent email requests to access their data sets. Only 1 publicly available data set could be accessed and only 6 out of 38 shared their data via email. So only 7/157 research articles shared their data sets, 4.5% (95% CI 1.8% to 9%). For 21 clinical trials bound by the BMJ data sharing policy, the per cent shared was 24% (8% to 47%).

Conclusions

Despite the BMJ's strong data sharing policy, sharing rates are low. Possible explanations for low data sharing rates could be: the wording of the BMJ data sharing policy, which leaves room for individual interpretation and possible loopholes; that our email requests ended up in researchers spam folders; and that researchers are not rewarded for sharing their data. It might be time for a more effective data sharing policy and better incentives for health and medical researchers to share their data.

Health status, disease spectrum and use of healthcare have been reported to vary across groups of migrants and according to the different phases of migration. However, most studies are conducted among adults. This study assesses usage of primary healthcare (PHC) by children with immigrant background compared with non-immigrant children in Norway and describes their relative morbidity burden.

Design

Population-based retrospective cohort study.

Setting

This study used 3 linked population-based registers in Norway for children under 18 years of age in 2008.

Main exposure and outcome measures

Immigrants were defined as children with both parents born abroad, and further classified into first and second generation, and according to the World Bank income categories of their parents' country of origin. Usage and morbidity were assessed with negative binomial regression and logistic regression analyses, respectively. Further, population-attributable fraction analyses on PHC visits were conducted to estimate the impact on the primary health system.

Participants

1 168 365 children including 119 251 with immigrant background.

Results

The mean number of visits to PHC for non-immigrant children was 1.40 compared with 1.19 for immigrants from high-income countries (HIC) and 1.76 for immigrants from low-income countries (LIC). Compared with non-immigrants, first generation immigrants used PHC significantly less after adjusting for age and sex (incidence risk ratio (IRR) 0.70 (HIC) to 0.93 (LIC)) while second generation immigrant children generally used PHC more (IRR 1.03 (HIC) to 1.43 (LIC)); however, the median number of visits were similar between all groups. The morbidity spectrum also varied between the groups.

Conclusions

Compared with non-immigrants, the excess number of consultations attributable to immigrant groups corresponds to around 1.3% of PHC visits among children.

Life course exposure to violence may lead to disability in old age. We examine associations and pathways between life course violence and mobility disability in older participants of the International Mobility in Aging Study (IMIAS).

Methods

A cross-sectional study using IMIAS 2012 baseline. Men and women aged 65–74 years were recruited at 5 cities (n=1995): Kingston and Saint-Hyacinthe (Canada), Tirana (Albania), Manizales (Colombia) and Natal (Brazil). Mobility was assessed by the Short Physical Performance Battery (SPPB) and by 2 questions on difficulty in walking and climbing stairs. Childhood physical abuse history and the HITS instrument were used to gather information on childhood exposure to violence and violence by intimate partners or family members. Multivariate logistic regression and mediation analysis models were constructed to explore the significance of direct and indirect effects of violence on mobility. Interaction effects of gender on violence and on each of the mediators were tested.

Results

Experiences of physical violence at any point of life were associated with mobility disability (defined as SPPB<8 or limitation in walking/climbing stairs) while psychological violence was not. Chronic conditions, C reactive protein, physical activity and depression mediated the effect of childhood exposure to violence on both mobility outcomes. Chronic conditions and depression were pathways between family and partner violence and both mobility outcomes. Physical activity was a significant pathway linking family violence to mobility. Gender interactions were not significant.

Conclusions

Our results provide evidence for the detrimental effects of life course exposure to violence on mobility in later life.

To enhance understanding of the experiences of ageing with cerebral palsy (CP) in adulthood with a particular focus on experiences with health services.

Design

A qualitative descriptive methodology was applied to capture adults' views of ageing with CP and related interactions with health services. Semistructured interviews were undertaken with data systematically coded and interpreted by grouping information into categories. Themes that encompassed the categories were identified through thematic analysis.

Setting

All healthcare settings.

Participants

28 adults (14 women) with CP, aged 37–70 years.

Results

5 themes covered the breadth of participants' experiences: (1) acceptance of change; (2) exploring identity: cerebral palsy as only one part of self; (3) taking charge of help; (4) rethinking the future and (5) interacting with health professionals. Being seen and being heard were the features described in positive healthcare interactions. Participants also valued health professionals who reflected on who holds the knowledge?; demonstrated a willingness to learn and respected participants' knowledge and experience.

Conclusions

Our findings could, and arguably should, inform more responsive strategies for disabled people in health services and, indeed, all health consumers. Our study supports other findings that impairments related to CP change and, for many, severity of disabling impact increases with age. Increased interactions with health and rehabilitation professionals, as a consequence of these changes, have the potential to impact the person's healthcare experience either positively or negatively. A ‘listening health professional’ may bridge their knowledge gap and, in recognising the person's own expertise, may achieve three things: a more contextualised healthcare intervention; a better healthcare experience for the person with CP and positive impact on the person's sense of autonomy and identity by recognising their expertise. Future research should identify whether this approach improves the healthcare experience for adults living with CP.

Abortion is a sensitive issue; many cultures disapprove of it, which leads to under-reporting. This study sought to estimate the rate of abortion visibility in the city of Kerman, Iran—that is, the percentage of acquaintances who knew about a particular abortion. For estimating the visibility rate, it is crucial to use the network scale-up method, which is a new, indirect method of estimating sensitive behaviours more accurately.

Materials and methods

This cross-sectional study was conducted in Kerman, Iran using various methods to ensure the cooperation of clinicians and women. A total of 222 women who had had an abortion within the previous year (74 elective, 74 medical and 74 spontaneous abortions) were recruited. Participants were asked how many of their acquaintances were aware of their abortion. Abortion visibility was estimated by abortion type. 95% CIs were calculated by a bootstrap procedure. A zero-inflated negative binomial regression analysis was conducted to assess the variables related to visibility.

Results

The visibility (95% CI) of elective, medical and spontaneous abortion was 8% (6% to 10%), 60% (54% to 66%) and 50% (43% to 57%), respectively. Women and consanguineal family were more likely to be aware of the abortion than men and affinal family. Non-family members had a low probability of knowing about the abortion, except in elective cases. Abortion type, marital status, sex of the acquaintance and closeness of the relationship were the most important determinants of abortion visibility in the final multifactorial model.

Conclusions

This study shows the visibility rate to be low, but it does differ among social network members and by the type of abortion in question. This difference might be explained through social and cultural norms as well as stigma surrounding abortion. The low visibility rate might explain the low estimates of abortion rates found in other studies.

In this cross-sectional epidemiological study we aimed to identify molecular profiles for Trichomonas vaginalis and to determine how these molecular profiles were related to patient demographic and clinical characteristics.

Setting

Molecular typing methods previously identified two genetically distinct subpopulations for T. vaginalis; however, few molecular epidemiological studies have been performed. We now increased the sensitivity of a previously described multilocus sequence typing (MLST) tool for T. vaginalis by using nested PCR. This enabled the typing of direct patient samples.

Participants

From January to December 2014, we collected all T. vaginalis positive samples as detected by routine laboratory testing. Samples from patients either came from general practitioners offices or from the sexually transmitted infections (STI) clinic in Amsterdam. Epidemiological data for the STI clinic patients were retrieved from electronic patient files.

Primary and secondary outcome measures

The primary outcome was the success rate of genotyping direct T. vaginalis positive samples. The secondary outcome was the relation between T. vaginalis genotypes and risk factors for STI.

Results

All 7 MLST loci were successfully typed for 71/87 clinical samples. The 71 typed samples came from 69 patients, the majority of whom were women (n=62; 90%) and half (n=34; 49%) were STI clinic patients. Samples segregated into a two population structure for T. vaginalis representing genotypes I and II. Genotype I was most common (n=40; 59.7%). STI clinic patients infected with genotype II reported more sexual partners in the preceding 6 months than patients infected with genotype I (p=0.028). No other associations for gender, age, ethnicity, urogenital discharge or co-occurring STIs with T. vaginalis genotype were found.

Primary outcome was consultation in primary care with the same musculoskeletal problem within 12 months. Secondary outcome measures were consultation at the CATS with the same musculoskeletal problem within 12 months, physical function and pain (Short Form-36), anxiety and depression (Hospital Anxiety and Depression Scale), time off work, healthcare costs and QALYs.

Results

Over 12 months, 507 (38%) reconsulted for the same problem in primary care and 345 (26%) at the CATS. Primary care reconsultation in the first 3 months was associated with baseline pain interference (relative risk ratio 5.33; 95% CI 3.23 to 8.80) and spinal pain (1.75; 1.09 to 2.82), and after 3–6 months with baseline assessment by a hospital specialist (2.06; 1.13 to 3.75). Small mean improvements were seen in physical function (1.88; 95% CI 1.44 to 2.32) and body pain (3.86; 3.38 to 4.34) at 6 months. Poor physical function at 6 months was associated with obesity, chronic pain and poor baseline physical function. Mean (SD) 6-month cost and QALYs per patient were £422.40 (660.11) and 0.257 (0.144), respectively.

Conclusions

While most patients are appropriate for a ‘one-stop shop’ model, those with troublesome, disabling pain and spinal pain commonly reconsult and have ongoing problems. Services should be configured to identify and address such clinical complexity.

Multiple rib fractures (RFs) and pulmonary contusions (PCs), with resulting systemic lung inflammation, are the most common injuries caused by blunt chest trauma (BCT) in motor vehicle accidents. This study examined levels of the inflammation marker interleukin (IL)-6 and those of the acute-phase reactant surfactant protein (SP)-D in patients with BCT.

The study included 60 patients with BCT who were hospitalised in our thoracic surgery department.

Parameters measures

The SP-D and IL-6 serum levels of patients with RFs (two or more RFs) (n=30) and patients with PCs (n=30) were measured after 6 hours, 24 hours and 7 days, and compared with those of age-matched and gender-matched healthy participants.

Results

The 6-hour serum SP-D levels of the RFs (p=0.017) and PCs (p<0.001) groups were significantly higher than those of the healthy controls. The 24-hour and 7-day SP-D levels of both groups were also higher than the control group. The serum IL-6 levels of both groups were significantly higher than those of the control group. We have found Injury Severity Score to be independently related to 6-hour IL-6 (β=1.414, p<0.001) and 24-hour IL-6 levels (β=1.067, p<0.001). The development of complications was independently related to 6-hour SP-D level (β=0.211, p=0.047).

Conclusions

RFs and PCs after BCT lead to local and systemic inflammation due to lung injury. The levels of the systemic inflammation marker IL-6 and those of the acute-phase reactant SP-D were elevated in the present study. The SP-D level may be used as a marker in the follow-up of BCT-related complications.

997 patients with HCV from 28 university-affiliated hospitals in China were enrolled in this research. Patients were divided into two subgroups.

Results

The prevalence of HBV infection in patients with HCV was 4.11% (41/997). The age-specific prevalence of HBsAg was 0.70%, 3.97% and 5.85% in groups aged 18–30, 30–50 and >50 years old (p=0.057), respectively. Patients with HBV/HCV dual infection and patients with HCV monoinfection had similar HCV viral loads (5.80±0.89 vs 5.83±1.00 log10 IU/mL, p=0.904). The dominant HCV genotype was 1b in both groups (53.65% vs 56.90%, p=0.493). The protective C allele in IL-28B (rs12979860) was also the dominant allele type in both patient groups (85.36% vs 83.99%, p=0.814). Patients with HBV/HCV dual infection had a higher ratio of liver cirrhosis and hepatic decompensation than patients with HCV monoinfection (39.02% vs 17.69%, p=0.001; 31.70% vs 12.13%, p=0.001).

Conclusions

The HBV burden was moderate in HCV-infected patients in China. Liver cirrhosis was more common in patients with HBV/HCV dual infection, suggesting the need for closer monitoring of dual-infected individuals.

Infant respiratory distress syndrome (IRDS) is a known risk factor for intracerebral haemorrhage/intraventricular haemorrhage (ICH/IVH) and periventricular leucomalacia. These lesions are known to increase the risk of cerebral palsy (CP). Thus, we wanted to examine the long-term risk of CP following IRDS in moderately late and late preterm infants.

Design

Population-based cohort study.

Setting

All hospitals in Denmark.

Participants

We used nationwide medical registries to identify a cohort of all moderately and late preterm infants (defined as birth during 32–36 full gestational weeks) born in Denmark in 1997–2007 with and without hospital diagnosed IRDS.

Main outcomes measures

We followed study participants from birth until first diagnosis of CP, emigration, death or end of follow-up in 2014. We computed the cumulative incidence of CP before age 8 years and used Cox's regression analysis to compute HRs of IRDS, comparing children with IRDS to those without IRDS. HRs were adjusted for multiple covariates.

Results

We identified 39 420 moderately late and late preterm infants, of whom 2255 (5.7%) had IRDS. The cumulative incidence of CP was 1.9% in infants with IRDS and 0.5% in the comparison cohort. The adjusted HR of CP was 2.0 (95% CI 1.4 to 2.9). The adjusted HR of CP was 12 (95% CI 4.5 to 34) in children with IRDS accompanied by a diagnosis of ICH/IVH. After restriction to children without diagnoses of perinatal breathing disorders other than IRDS, congenital heart disease and viral or bacterial infections occurring within 4 days of birth, the overall adjusted HR was 2.1 (95% CI 1.4 to 3.1).

Conclusions

The risk of CP was increased in moderately late and late preterm infants with IRDS compared with infants without IRDS born during the same gestational weeks.

Glaucoma, a chronic non-communicable disease, and leading cause of irreversible blindness worldwide is a public health problem in Nigeria, with a prevalence of 5.02% in people aged ≥40 years. The purpose of this nationwide survey was to assess Nigerian ophthalmologists’ practice patterns and their constraints in managing glaucoma.

Study design

Ophthalmologists were sent a semistructured questionnaire on how they manage glaucoma, their training in glaucoma care, where they practice, their access to equipment for diagnosis and treatment, whether they use protocols and the challenges they face in managing patients with glaucoma.

Results

153/250 ophthalmologists in 80 centres completed questionnaires. Although 79% felt their training was excellent or good, 46% needed more training in glaucoma diagnosis and surgery. All had ophthalmoscopes, 93% had access to applanation tonometers, 81% to visual field analysers and 29% to laser machines (in 19 centres). 3 ophthalmologists had only ophthalmoscopes and schiøtz tonometers. For 85%, a glaucomatous optic disc was the most important feature that would prompt glaucoma work-up. Only 56% routinely performed gonioscopy and 61% used slit-lamp stereoscopic biomicroscopy for disc assessment. Trabeculectomy (with/without antimetabolites) was the only glaucoma surgery performed with one mention of canaloplasty. Poor compliance with medical treatment (78%) and low acceptance of surgery (71%) were their greatest challenges.

Conclusions

This study indicates that a systems-oriented approach is required to enhance ophthalmologist's capability for glaucoma care. Strategies to improve glaucoma management include strengthening poorly equipped centres including provision of lasers and training, and improving patients’ awareness and education on glaucoma.

At least 30% of young people with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) also have symptoms of depression. This systematic review aimed to establish which treatment approaches for depression are effective and whether comorbid depression mediates outcome.

Setting

A systematic review was undertaken. The search terms were entered into MEDLINE, EMBASE, PsycInfo and the Cochrane library.

Participants

Inclusion and exclusion criteria were applied to identify relevant papers. Inclusion criteria were children age <18, with CFS/ME, defined using CDC, NICE or Oxford criteria, and having completed a valid assessment for depression.

Results

9 studies were identified which met the inclusion criteria, but none specifically tested treatments for paediatric CFS/ME with depression and none stratified outcome for those who were depressed compared with those who were not depressed. There is no consistent treatment approach for children with CFS/ME and comorbid depression, although cognitive–behavioural therapy for CFS/ME and a multicomponent inpatient programme for CFS/ME have shown some promise in reducing depressive symptoms. An antiviral medication in a small scale, retrospective, uncontrolled study suggested possible benefit.

Conclusions

It is not possible to determine what treatment approaches are effective for depression in paediatric CFS/ME, nor to determine the impact of depression on the outcome of CFS/ME treatment. Young people with significant depression tend to have been excluded from previous treatment studies.

To investigate the association between student performance in undergraduate objective structured clinical examinations (OSCEs) and the examination schedule to which they were assigned to undertake these examinations.

Design

Analysis of routinely collected data.

Setting

One UK medical school.

Participants

2331 OSCEs of 3 different types (obstetrics OSCE, paediatrics OSCE and simulated clinical encounter examination OSCE) between 2009 and 2013. Students were not quarantined between examinations.

Outcomes

(1) Pass rates by day examination started, (2) pass rates by day station undertaken and (3) mean scores by day examination started.

Results

We found no evidence that pass rates differed according to the day on which the examination was started by a candidate in any of the examinations considered (p>0.1 for all). There was evidence (p=0.013) that students were more likely to pass individual stations on the second day of the paediatrics OSCE (OR 1.27, 95% CI 1.05 to 1.54). In the cases of the simulated clinical encounter examination and the obstetrics and gynaecology OSCEs, there was no (p=0.42) or very weak evidence (p=0.099), respectively, of any such variation in the probability of passing individual stations according to the day they were attempted. There was no evidence that mean scores varied by day apart from the paediatric OSCE, where slightly higher scores were achieved on the second day of the examination.

Conclusions

There is little evidence that different examination schedules have a consistent effect on pass rates or mean scores: students starting the examinations later were not consistently more or less likely to pass or score more highly than those starting earlier. The practice of quarantining students to prevent communication with (and subsequent unfair advantage for) subsequent examination cohorts is unlikely to be required.

To identify publication and citation trends, most productive institutions and countries, top journals, most cited articles and authorship networks from articles that used and analysed data from primary care databases (CPRD, THIN, QResearch) of pseudonymised electronic health records (EHRs) in UK.

Methods

Descriptive statistics and scientometric tools were used to analyse a SCOPUS data set of 1891 articles. Open access software was used to extract networks from the data set (Table2Net), visualise and analyse coauthorship networks of scholars and countries (Gephi) and density maps (VOSviewer) of research topics co-occurrence and journal cocitation.

Results

Research output increased overall at a yearly rate of 18.65%. While medicine is the main field of research, studies in more specialised areas include biochemistry and pharmacology. Researchers from UK, USA and Spanish institutions have published the most papers. Most of the journals that publish this type of research and most cited papers come from UK and USA. Authorship varied between 3 and 6 authors. Keyword analyses show that smoking, diabetes, cardiovascular diseases and mental illnesses, as well as medication that can treat such medical conditions, such as non-steroid anti-inflammatory agents, insulin and antidepressants constitute the main topics of research. Coauthorship network analyses show that lead scientists, directors or founders of these databases are, to various degrees, at the centre of clusters in this scientific community.

Conclusions

There is a considerable increase of publications in primary care research from EHRs. The UK has been well placed at the centre of an expanding global scientific community, facilitating international collaborations and bringing together international expertise in medicine, biochemical and pharmaceutical research.

Tackling the harm associated with acute kidney injury (AKI) is a global priority. In England, a national computerised AKI algorithm is being introduced across the National Health Service (NHS) to drive this change. The study sought to maximise its clinical utility and minimise the potential for burden on clinicians and patients in primary care.

Design

An appropriateness ratings evaluation using the RAND/UCLA Appropriateness Method.

A 10-person panel was purposively sampled with representation from clinical biochemistry, acute and emergency medicine and general practice. General practitioners (GPs) represented typical practice in relation to rural and urban practice, out of hours care, GP commissioning and those interested in reducing the impact of medicalisation and ‘overdiagnosis’.

Results

There was agreement that delivery of AKI warning stage test results through interruptive methods of communication (ie, telephone) from laboratories to primary care was the appropriate next step for patients with an AKI warning stage 3 test result. In the context of acute illness, waiting up to 72 hours to respond to an AKI warning stage test result was deemed an inappropriate action in 62 out of the 65 (94.5%) cases. There was agreement that a clinician response was required within 6 hours, or less, in 39 out of 40 (97.5%) clinical cases relating AKI warning stage test results in the presence of moderate hyperkalaemia.

Conclusions

The study has informed national guidance to support a timely and calibrated response to AKI warning stage test results for adults in primary care. Further research is needed to support effective implementation, with a view to examine the effect on health outcomes and costs.

A total of 410 studies were located, with 46 meeting the inclusion criteria. The majority employed a cross-sectional design, involved participants aged 11–18 years, and were conducted in North America or Europe. Consumption of energy drinks by children and young people was found to be patterned by gender, with boys consuming more than girls, and also by activity levels, with the highest consumption observed in the most and least sedentary individuals. Several studies identified a strong, positive association between the use of energy drinks and higher odds of health-damaging behaviours, as well as physical health symptoms such as headaches, stomach aches, hyperactivity and insomnia. There was some evidence of a dose–response effect. 2 experimental studies involving small numbers of junior athletes demonstrated a positive impact on limited aspects of sports performance. 3 themes emerged from the qualitative studies: reasons for use; influences on use; and perceived efficacy and impact. Taste and energy-seeking were identified as key drivers, and branding and marketing were highlighted as major influences on young people's consumption choices. Awareness of possible negative effects was low.

Conclusions

There is growing evidence that consumption of energy drinks is associated with a range of adverse outcomes and risk behaviours in terms of children's health and well-being. However, taste, brand loyalty and perceived positive effects combine to ensure their popularity with young consumers. More research is needed to explore the short-term and long-term impacts in all spheres, including health, behaviour and education.

The incidence of cervical cancer is up to 20-fold higher among First Nations women in Canada than the general population, probably due to lower participation in screening. Offering human papillomavirus (HPV) self-sampling in place of Papanicolaou (Pap) testing may eventually increase screening participation and reduce cervical cancer rates in this population.

Design

A community-randomised controlled screening trial.

Setting

First Nations communities in Northwest Ontario, Canada.

Participants

Women aged between 25 and 69, living in Robinson Superior Treaty First Nations. The community was the unit of randomisation.

Interventions

Women were asked to complete a questionnaire and have screening by HPV self-sampling (arm A) or Pap testing (arm B).

Primary outcome measures

The number of women who participated in cervical screening.

Randomisation

Community clusters were randomised to include approximately equivalent numbers of women in each arm.

Pap and HPV self-sampling were compared in a marginalised, Canadian population. Results indicated a preference for self-sampling. More research on how to reach underscreened Indigenous women is necessary.

Nursing home residents (NHRs) are frequently suffering from multimorbidity, functional and cognitive impairment, often leading to hospital admissions. Studies have found that male NHRs are more often hospitalised. The influence of age is inconclusive. We aimed to investigate the epidemiology of hospitalisations in NHRs, particularly focusing on age-specific and sex-specific differences.

Design

A systematic review was performed in PubMed, CINAHL and Scopus. Quality of studies was assessed.

Setting

Studies conducted in nursing homes were included.

Participants

Nursing home residents.

Primary and secondary outcomes

Outcome measures were the prevalence, incidence or duration of all-cause hospitalisation by age or sex.

Results

We identified 21 studies, 13 were conducted in the USA. The proportion of residents being hospitalised ranged across studies from 6.8% to 45.7% for various time periods of follow-up. A total of 20 studies assessed the influence of sex and found that hospitalisations are more often in male NHRs. A total of 16 studies conducted multivariate analyses and the OR of hospitalisation for males was between 1.22 and 1.67. Overall, 18 studies assessed the influence of age. Some studies showed an increasing proportion of admissions with increasing age, but several studies also found decreasing hospitalisations above the age of about 80–85 years. 8 of 13 studies conducting multivariate analyses included age as a continuous variable. Only 1 study reported stratified analyses by age and sex. 2 studies investigating primary causes of hospitalisation stratified by sex found some differences in main diagnoses.

Discussion

Male NHRs are more often hospitalised than females, but reasons for that are not well investigated. The influence of age is less clear, but there seems to be no clear linear relationship between age and the proportion being hospitalised. Further studies should investigate age and sex differences in frequencies and reasons for hospitalisation in NHRs.

The use and combined use of psychotropic drugs and alcohol among older adults is a growing public health concern and should be constantly monitored. Relevant studies are scarce in Germany. Using data of the most recent national health survey, we analyse prevalence and correlates of psychotropic drug and alcohol use among this population.

Methods

Study participants were people aged 60–79 years (N=2508) of the German Health Interview and Examination Survey for Adults 2008–2011. Medicines used during the last 7 days were documented. Psychotropic drugs were defined as medicines acting on the nervous system (ATC code N00) excluding anaesthetics (N01), analgesics/antipyretics (N02B), but including opiate codeines used as antitussives (R05D). Alcohol consumption in the preceding 12 months was measured by frequency (drinking any alcohol-containing beverages at least once a week/a day) and quantity (alcohol consumed in grams/day; cut-offs: 10/20 g/day for women/men defining moderate and risky drinking). SPSS complex sample module was used for analysis.

Despite the high risk of synergetic effects of psychotropic drugs and alcohol, a substantial part of older psychotropic drug users consume alcohol riskily and daily. Health professionals should talk about the additional health risks of alcohol consumption when prescribing psychotropic drugs to older adults.

Approximately 15 million babies were born preterm worldwide in 2010 and in England in 2014 there were 52 249 preterm births. Preterm babies are at increased risk of poor outcomes and this can put enormous strain on the family.

Objective

This study aimed to test the hypothesis that giving birth preterm affects maternal health, mood and well-being, and alters women's feelings and perceptions about their baby.

Methods

Data collected in a population-based survey of maternity care in England in 2014 were used. Women were randomly selected and asked about their pregnancy, birth and postnatal experience when their babies were about 3 months of age. Descriptive statistics were produced, and logistic regression used to estimate ORs, adjusted for key confounders.

4578 women returned completed questionnaires. Of these, 42 (0.9%) had babies born before 32 weeks' gestation and 243 (5.5%) at 32–36 weeks. Comparing the three gestational age groups, no statistically significant differences in rates of depressive symptoms measured on the Edinburgh Postnatal Depression Scale were found. However, using a health problems checklist, anxiety, fatigue and flash-backs were more common in mothers of preterm babies. Overall, mothers of preterm babies had less early contact with their baby, more postnatal health problems, substantially less positive feelings towards their baby and made less use of the support options available.

Conclusions

Women with preterm births are at increased risk of ill-health and negative feelings about their baby in the early months after birth. They make less use of postnatal services and support than other women and this may be an area where the use of specialist services would be appropriate.

To create and validate an objective and reliable score to assess referral quality in gastroenterology.

Design

An observational multicentre study.

Setting and participants

25 gastroenterologists participated in selecting variables for a Thirty Point Score (TPS) for quality assessment of referrals to gastroenterology specialist healthcare for 9 common indications. From May to September 2014, 7 hospitals from the South-Eastern Norway Regional Health Authority participated in collecting and scoring 327 referrals to a gastroenterologist.

Main outcome measure

Correlation between the TPS and a visual analogue scale (VAS) for referral quality.

Results

The 327 referrals had an average TPS of 13.2 (range 1–25) and an average VAS of 4.7 (range 0.2–9.5). The reliability of the score was excellent, with an intra-rater intraclass correlation coefficient (ICC) of 0.87 and inter-rater ICC of 0.91. The overall correlation between the TPS and the VAS was moderate (r=0.42), and ranged from fair to substantial for the various indications. Mean agreement was good (ICC=0.47, 95% CI (0.34 to 0.57)), ranging from poor to good.

Conclusions

The TPS is reliable, objective and shows good agreement with the subjective VAS. The score may be a useful tool for assessing referral quality in gastroenterology, particularly important when evaluating the effect of interventions to improve referral quality.

The British Government is acting on recommendations to overhaul postgraduate training to meet the needs of the changing population, to produce generalist doctors undergoing shorter broad-based training (Greenaway Review). Only 45 doctors in training were involved in the consultation process. This study aims to obtain a focused perspective on the proposed reforms by doctors in training from across specialities.

Design

Prospective, questionnaire-based cross-sectional study.

Setting/participants

Following validation, a 31-item electronic questionnaire was distributed via trainee organisations and Postgraduate Local Education and Training Board (LETB) mailing lists. Throughout the 10-week study period, the survey was publicised on several social media platforms.

Results

Of the 3603 demographically representative respondents, 69% knew about proposed changes. Of the respondents, 73% expressed a desire to specialise, with 54% keen to provide general emergency cover. A small proportion (12%) stated that current training pathway length is too long, although 86% felt that it is impossible to achieve independent practitioner-level proficiency in a shorter period of time than is currently required. Opinions regarding credentialing were mixed, but tended towards disagreement. The vast majority (97%) felt credentialing should not be funded by doctors in training. Respondents preferred longer placement lengths with increasing career progression. Doctors in training value early generalised training (65%), with suggestions for further improvement.

Conclusions

This is the first large-scale cross-specialty study regarding the Shape of Training Review. Although there are recommendations which trainees support, it is clear that one size does not fit all. Most trainees are keen to provide a specialist service on an emergency generalist background. Credentialing is a contentious issue; however, we believe removing aspects from curricula into post-Certificate of Completion of Training (CCT) credentialing programmes with shortened specialty training routes only degrades the current consultant expertise, and does not serve the population. Educational needs, not political winds, should drive changes in postgraduate medical education and all stakeholders should be involved.

We aim to describe the intention to quit smoking among Chinese male smokers from different educational backgrounds and to explain this intention from their attitude, perceived social norms and self-efficacy regarding smoking cessation.

Setting

Participants were recruited from workplaces and communities to reflect the occupational distribution in three cities (Shanghai, Nanning and Mudanjiang) in China.

Design and participants

In 2013 interviews were conducted with 3676 male smokers aged 18 years and older.

Outcome measures

Multivariate logistic regression analyses calculated educational differences in the intention to quit smoking as well as the association between the intention to quit smoking and attitude, subjective norms, and self-efficacy. Bootstrapping estimated to what extent the educational disparities in the intention to quit smoking were mediated by these three determinants.

Results

No educational disparities in the intention to quit smoking within 1 or 6 months were observed among male Chinese smokers (p=0.623 and p=0.153, respectively). A less negative attitude, a higher perceived subjective norm towards smoking cessation, and a higher perceived self-efficacy to quit smoking were all associated with intention to quit (all p values <0.001). Perceived subjective norms were the only component of the theory of planned behaviour that statistically significantly mediated the differences in the intention to quit smoking (within 1 or 6 months) between the lowest educated Chinese men and the groups with lower (β=0.039, 95% CI 0.017 to 0.071 and β=0.043, 95% CI 0.019 to 0.073), higher (β=0.041, 95% CI 0.017 to 0.075 and β=0.045, 95% CI 0.019 to 0.077) and the highest education (β=0.045, 95% CI 0.019 to 0.080 and β=0.050, 95% CI 0.023 to 0.083).

Conclusions

In order to prevent future socioeconomic disparities in smoking cessation, investment in a more stimulating social environment and norms towards smoking cessation among particularly the lowest educated Chinese men is warranted.

To compare the enhanced recovery after surgery (ERAS) protocol compliance and clinical outcomes depending on the weekday of surgery.

Settings

Cohort of consecutive non-selected patients undergoing elective colorectal surgery from January 2012 to March 2015. This retrospective analysis of our prospective database compared patients operated early in the week (Monday and Tuesday) with patients operated in the second half (late: Thursday, Friday).

Primary outcome measures

Compliance with the ERAS protocol, functional recovery, complications and length of stay.

Results

Demographic and surgical details were similar between the early (n=352) and late groups (n=204). Overall compliance with the ERAS protocol was 78% vs 76% for the early and late groups, respectively (p=0.009). Significant differences were notably prolonged urinary drainage and intravenous fluid infusion in the late group. Complication rates and length of stay, however, were not different between surgery on Monday or Tuesday and surgery on Thursday or Friday.

Conclusions

Application of the ERAS protocol showed only minor differences for patients operated on early or late during the week, and clinical outcomes were similar. A fully implemented ERAS programme appears to work also over the weekend.

Most UK medical programmes use aptitude tests during student selection, but large-scale studies of predictive validity are rare. This study assesses the UK Clinical Aptitude Test (UKCAT: http://www.ukcat.ac.uk), and 4 of its subscales, along with individual and contextual socioeconomic background factors, as predictors of performance during, and on exit from, medical school.

Methods

This was an observational study of 6294 medical students from 30 UK medical programmes who took the UKCAT from 2006 to 2008, for whom selection data from the UK Foundation Programme (UKFPO), the next stage of UK medical education training, were available in 2013. We included candidate demographics, UKCAT (cognitive domains; total scores), UKFPO Educational Performance Measure (EPM) and national exit situational judgement test (SJT). Multilevel modelling was used to assess relationships between variables, adjusting for confounders.

Results

The UKCAT—as a total score and in terms of the subtest scores—has significant predictive validity for performance on the UKFPO EPM and SJT. UKFPO performance was also affected positively by female gender, maturity, white ethnicity and coming from a higher social class area at the time of application to medical school An inverse pattern was seen for a contextual measure of school, with those attending fee-paying schools performing significantly more weakly on the EPM decile, the EPM total and the total UKFPO score, but not the SJT, than those attending other types of school.

Conclusions

This large-scale study, the first to link 2 national databases—UKCAT and UKFPO, has shown that UKCAT is a predictor of medical school outcome. The data provide modest supportive evidence for the UKCAT's role in student selection. The conflicting relationships of socioeconomic contextual measures (area and school) with outcome adds to wider debates about the limitations of these measures, and indicates the need for further research.

Prevalent adult patients with CKD 4 or 5 (n=1046, mean age 68 years), on peritoneal dialysis (n=101; 64 years), on haemodialysis (n=460; 65 years) and with renal transplants (n=825; 52 years) were identified in Stockholm County clinical quality registers for renal disease on 1 January 2010. 5 general population comparators from the same county were matched to each patient by age, sex and index year.

Primary and secondary outcome measures

Annual healthcare costs in 2009 incurred through inpatient and hospital-based outpatient care and dispensed prescription drugs ascertained from nationwide healthcare registers. Secondary outcomes were annual number of hospital days and outpatient care visits.

Results

Patients on haemodialysis had the highest mean annual cost (87 600), which was 1.49 (95% CI 1.38 to 1.60) times that observed in peritoneal dialysis (58 600). The mean annual cost was considerably lower in transplanted patients (15 500) and in the CKD group (9600). In patients on haemodialysis, outpatient care costs made up more than two-thirds (62 500) of the total, while costs related to fluids ($29 900) was the largest cost component in patients on peritoneal dialysis (51%). Compared with their matched general population comparators, the mean annual cost (95% CI) in patients on haemodialysis, peritoneal dialysis, transplanted patients and patients with CKD was 45 (39 to 51), 29 (22 to 37), 11 (10 to 13) and 4.0 (3.6 to 4.5) times higher, respectively.

Conclusions

The mean annual costs were ~50% higher in patients on haemodialysis than in those on peritoneal dialysis. Compared with the general population, costs were substantially elevated in all groups, from 4-fold in patients with CKD to 11, 29 and 45 times higher in transplanted patients and patients on peritoneal dialysis and haemodialysis, respectively.

Identification of sufficiently trustworthy top 5 list recommendations from the US Choosing Wisely campaign.

Setting

Not applicable.

Participants

All top 5 list recommendations available from the American Board of Internal Medicine Foundation website.

Main outcome measures/interventions

Compilation of US top 5 lists and search for current German highly trustworthy (S3) guidelines. Extraction of guideline recommendations, including grade of recommendation (GoR), for suggestions comparable to top 5 list recommendations. For recommendations without guideline equivalents, the methodological quality of the top 5 list development process was assessed using criteria similar to that used to judge guidelines, and relevant meta-literature was identified in cited references. Judgement of sufficient trustworthiness of top 5 list recommendations was based either on an ‘A’ GoR of guideline equivalents or on high methodological quality and citation of relevant meta-literature.

Results

412 top 5 list recommendations were identified. For 75 (18%), equivalents were found in current German S3 guidelines. 44 of these recommendations were associated with an ‘A’ GoR, or a strong recommendation based on strong evidence, and 26 had a ‘B’ or a ‘C’ GoR. No GoR was provided for 5 recommendations. 337 recommendations had no equivalent in the German S3 guidelines. The methodological quality of the development process was high and relevant meta-literature was cited for 87 top 5 list recommendations. For a further 36, either the methodological quality was high without any meta-literature citations or meta-literature citations existed but the methodological quality was lacking. For the remaining 214 recommendations, either the methodological quality was lacking and no literature was cited or the methodological quality was generally unsatisfactory.

Conclusions

131 of current US top 5 list recommendations were found to be sufficiently trustworthy. For a substantial number of current US top 5 list recommendations, their trustworthiness remains unclear. Methodological requirements for developing top 5 lists are recommended.

Collaborative care consisted of evidence-based low-intensity psychological treatments, delivered over 3 months and case management by a practice nurse and a Psychological Well Being Practitioner.

Outcome measures

As planned, the primary measure of cost-effectiveness was the incremental cost-effectiveness ratio (cost per quality-adjusted life year (QALY)). A Markov model was constructed to extrapolate the trial results from short-term to long-term (24 months).

Results

The mean cost per participant of collaborative care was £317 (95% CI 284 to 350). Over 24 months, it was estimated that collaborative care was associated with greater healthcare usage costs (net cost £674 (95% CI –30 953 to 38 853)) and QALYs (net QALY gain 0.04 (95% CI –0.46 to 0.54)) than usual care, resulting in a cost per QALY gained of £16 123, and a likelihood of being cost-effective of 0.54 (willingness to pay threshold of £20 000).

Conclusions

Collaborative care is a potentially cost-effective long-term treatment for depression in patients with comorbid physical and mental illness. The estimated cost per QALY gained was below the threshold recommended by English decision-makers. Further, long-term primary research is needed to address uncertainty associated with estimates of cost-effectiveness.

To assess the adequacy of reporting of non-inferiority trials alongside the consistency and utility of current recommended analyses and guidelines.

Design

Review of randomised clinical trials that used a non-inferiority design published between January 2010 and May 2015 in medical journals that had an impact factor >10 (JAMA Internal Medicine, Archives Internal Medicine, PLOS Medicine, Annals of Internal Medicine, BMJ, JAMA, Lancet and New England Journal of Medicine).

Data sources

Ovid (MEDLINE).

Methods

We searched for non-inferiority trials and assessed the following: choice of non-inferiority margin and justification of margin; power and significance level for sample size; patient population used and how this was defined; any missing data methods used and assumptions declared and any sensitivity analyses used.

Results

A total of 168 trial publications were included. Most trials concluded non-inferiority (132; 79%). The non-inferiority margin was reported for 98% (164), but less than half reported any justification for the margin (77; 46%). While most chose two different analyses (91; 54%) the most common being intention-to-treat (ITT) or modified ITT and per-protocol, a large number of articles only chose to conduct and report one analysis (65; 39%), most commonly the ITT analysis. There was lack of clarity or inconsistency between the type I error rate and corresponding CIs for 73 (43%) articles. Missing data were rarely considered with (99; 59%) not declaring whether imputation techniques were used.

Conclusions

Reporting and conduct of non-inferiority trials is inconsistent and does not follow the recommendations in available statistical guidelines, which are not wholly consistent themselves. Authors should clearly describe the methods used and provide clear descriptions of and justifications for their design and primary analysis. Failure to do this risks misleading conclusions being drawn, with consequent effects on clinical practice.

To investigate opposition to standardised tobacco packaging in the UK. To increase understanding of how transnational corporations are adapting to changes in their access to policymakers precipitated by Article 5.3 of the Framework Convention on Tobacco Control (FCTC).

Design

Case study web-based documentary analysis, using NVivo V.10. Examination of relationships between opponents of standardised packaging and transnational tobacco companies (TTCs) and of the volume, nature, transparency and timing of their activities.

Excluding tobacco manufacturing and packaging companies (n=12), 109 organisations were involved in opposing standardised packaging, 82 (75%) of which had a financial relationship with 1 or more TTC. These 82 organisations (43 actively opposing the measure, 39 facilitating opposition) were responsible for 60% of the 404 activities identified, including the majority of public communications and research production. TTCs were directly responsible for 28% of total activities, predominantly direct lobbying, but also financially underwrote third party research, communication, mass recruitment and lobbying. Active organisations rarely reported any financial relationship with TTCs when undertaking opposition activities.

Conclusions

The multifaceted opposition to standardised packaging was primarily undertaken by third parties with financial relationships with major tobacco manufacturers. Low levels of transparency regarding these links created a misleading impression of diverse and widespread opposition. Countries should strengthen implementation of Article 5.3 of the FCTC by systematically requiring conflict of interest declarations from all organisations participating in political or media debates on tobacco control.

To describe patterns of experimentation with electronic cigarettes as a smoking cessation aid, their self-reported impact on smoking cessation and to identify factors associated with self-reported successful quit attempts within the European Union (EU).

Design

A cross-sectional study.

Setting

28 European Union member states.

Methods

We analysed data from wave 82.4 of the Special Eurobarometer survey, collected in December 2014 from all 28 EU member states. The total sample size was n=27 801 individuals aged ≥15 years; however, our analyses were conducted in different subgroups with sample sizes ranging from n=470 to n=9363. Data on e-cigarette experimentation and its self-reported impact on smoking cessation were collected. Logistic regression models were used to assess factors associated with experimentation of e-cigarettes as cessation aids and with successful quitting. Logistic regression was also used to assess changes in the use of e-cigarettes as cessation aids between 2012 (using data from wave 77.1 of the Eurobarometer) and 2014 in each member state.

Results

E-cigarettes were often experimented with as a cessation aid, especially among younger smokers (OR=5.29) and those who reported financial difficulties (OR=1.33). In total, 10.6% of those who had ever attempted to quit smoking and 27.4% of those who did so using a cessation aid had experimented with e-cigarettes as a cessation aid. Among those who had used e-cigarettes as a cessation aid, those with higher education were more likely to have been successful in quitting (OR=2.23). There was great variation in trends of use of e-cigarette as a cessation aid between member states.

Conclusions

Experimentation with e-cigarettes as a potential cessation aid at a population level has increased throughout the EU in recent years, and certain population groups are more likely to experiment with them as cessation aids. Research on the potential population impact of these trends is imperatively needed.

To examine the factors associated with hope and hopelessness in patients with cancer in Asian countries, and the instruments used to measure hope and hopelessness.

Methords

A comprehensive systematic review was conducted with search terms, including cancer, hope, hopelessness and individual Asian country names, on CINAHL, Embase, PsycINFO, PubMed and Scopus databases. Only quantitative studies on adult cancer populations in Asia examining hope or hopelessness were included.

Results

A total of 2062 unique articles were retrieved from the databases, and 32 studies were selected for inclusion in this review. Hope and hopelessness were most frequently measured with the Herth Hope Index and the Mental Adjustment to Cancer Scale, respectively. The biopsychosocial factors that were most consistently associated with hope and hopelessness included sociodemographic variables (education, employment and economic status); clinical factors (cancer stage, physical condition and symptoms); and psychosocial factors (emotional distress, social support and connections, quality of life, control or self-efficacy, as well as adjustment and resilience).

Discussion

There is a need for more studies from South and Southeast Asia as most studies hailed from East Asia. This review highlighted the possibility of cultural differences influencing factors related to hope, suggesting that cross-cultural studies specifically would facilitate understanding behind these variations, although future reviews on hope should also include studies on hopelessness for a comprehensive understanding of the concept. Finally, more longitudinal research could be conducted to assess whether the factors associated with hope and hopelessness change over time and disease progression.

The majority of Chinese families were under either one-child or two-child birth control policy status from 2001 to 2015. We explore the association between an infant's sex and the mother's postpartum well-being, which may be moderated by birth control policy status in China.

Setting and participants

We conducted a prospective cohort study in Shanghai City, one of the largest cities in China. A total number of 1730 childbearing women from eight obstetric hospitals across Shanghai were included in the study at baseline, with 1503 women completing the survey 7 days postpartum in 2013.

Measures

The General Well-Being Schedule (GWBS) was used to assess maternal well-being at baseline and follow-up investigation in the study. The women's demographic, clinical characteristics, and well-being were measured at baseline. Maternal satisfaction and postpartum well-being were assessed in the follow-up survey.

Results

Multivariable linear regression analyses showed that women who gave birth to male infants were positively associated with the total score of maternal well-being, when the participating hospitals, maternal well-being at baseline, sociodemographic characteristics, and maternal and infant health outcomes were added to the adjustments (β=1.462, p<0.05). The association disappeared when the two-child policy status was added to the adjustments (p>0.05). The results of a multiple logistic regression model showed that having a male infant was a risk factor of ‘severe distress’ (OR=1.607, p<0.05), which was moderated by the two-child policy status (p>0.05).

Conclusions

Our results emphasise the importance of conducting interventions to increase maternal general well-being, especially for those with a female infant in a society such as China where preference is for a son, and enhance the necessity of sustainability of a newly relaxed two-child policy which allows more couples to have a second child in China.

Different diagnostic algorithms for non-acute heart failure (HF) exist. Our aim was to compare the ability of these algorithms to identify HF in symptomatic patients aged 80 years and older and identify those patients at highest risk for mortality.

Design

Diagnostic accuracy and validation study.

Setting

General practice, Belgium.

Participants

365 patients with HF symptoms aged 80 years and older (BELFRAIL cohort). Participants underwent a full clinical assessment, including a detailed echocardiographic examination at home.

Outcome measures

The diagnostic accuracy of 4 different algorithms was compared using an intention-to-diagnose analysis. The European Society of Cardiology (ESC) definition of HF was used as the reference standard for HF diagnosis. Kaplan-Meier curves for 5-year all-cause mortality were plotted and HRs and corresponding 95% CIs were calculated to compare the mortality risk predicting abilities of the different algorithms. Net reclassification improvement (NRI) was calculated.

Choosing a diagnostic algorithm for non-acute HF in elderly patients represents a trade-off between sensitivity and specificity, mainly depending on differences between cut-off values for natriuretic peptides.

Toxoplasma gondii is an obligate intracellular protozoan infecting up to one-third of the world's population, constituting a life threat if transmitted from mother to child during pregnancy. In Portugal, there is a lack of knowledge of the current epidemiological situation, as the unique toxoplasmosis National Serological Survey was performed in 1979/1980.

Methods

We studied the seroprevalence trends in the Portuguese general population over the past 3 decades, by assessing chronological spread cross-sectional studies, with special focus on women of childbearing age, by age group, region and gender.

Results

The T. gondii overall seroprevalence decreased from 47% in 1979/1980 to 22% (95% CI 20% to 24%) in 2013. Generally, we observed that the prevalence of T. gondii IgG increased significantly with age and it decreased over time, both in the general population and in the childbearing women (18% prevalence in 2013).

Conclusions

The scenario observed for the latter indicates that more than 80% of childbearing women are susceptible to primary infection yielding a risk of congenital toxoplasmosis and respective sequelae. Since there is no vaccine to prevent human toxoplasmosis, the improvement of primary prevention constitutes a major tool to avoid infection in such susceptible groups.

CINAHL, EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science were searched from January 2000 to April 2015.

Eligibility criteria for selecting studies

Systematic reviews and qualitative metasyntheses where the participants were patients, caregivers and which described experiences of care for CHF, COPD and CKD in primary and secondary care who were aged ≥18 years.

Results

Searches identified 5420 articles, 53 of which met inclusion criteria. Reviews showed that patients' and caregivers' help seeking and decision-making were shaped by their degree of structural advantage (socioeconomic status, spatial location, health service quality); their degree of interactional advantage (cognitive advantage, affective state and interaction quality) and their degree of structural resilience (adaptation to adversity, competence in managing care and caregiver response to demands).

Conclusions

To the best of our knowledge, this is the first synthesis of qualitative systematic reviews in the field. An important outcome of this overview is an emphasis on what patients and caregivers value and on attributes of healthcare systems, relationships and practices that affect the distressing effects and consequences of pathophysiological deterioration in CHF, COPD and CKD. Interventions that seek to empower individual patients may have limited effectiveness for those who are most affected by the combined weight of structural, relational and practical disadvantage identified in this overview. We identify potential targets for interventions that could address these disadvantages.

To determine, in the context of primary care preventive health services, the level of importance that Portuguese patients attribute to different preventive activities.

Design

Cross-sectional study.

Setting

Primary Healthcare, Portugal.

Participants

1000 Portuguese adults selected by a stratified cluster sampling design were invited to participate in a computer-assisted telephone survey. Persons with a cognitive or physical disability that hampered the ability to complete a telephone interview and being a nursing home resident or resident in any other type of collective dwelling were excluded.

Outcomes

Mean level of importance assigned to 20 different medical preventive activities, using a scale of 1–10, with 1 corresponding to ‘no importance for you and your health’ and 10 indicating ‘very important’.

Results

The mean level of importance assigned to medical preventive activity was 7.70 (95% CI 7.60 to 7.80). Routine blood and urine tests were considered the most important, with an estimated mean of 9.15 (95% CI 9.07 to 9.24), followed by female-specific interventions (Pap smear, mammography and gynaecological and breast ultrasounds), with mean importance ranging from 8.45 (95% CI 8.23 to 8.63) for mammography to 8.56 (95% CI 8.36 to 8.76) for Pap smear. Advice regarding alcohol consumption (6.18; 95% CI 5.96 to 6.39) and tobacco consumption (5.99; 95% CI 5.75 to 6.23) were considered much less important.

Conclusions

Our results reveal that Portuguese patients overestimate the importance of preventive medical activities, tend to give more importance to diagnostic and laboratory tests than to lifestyle measures, do not discriminate tests that are important and evidence-based, and seem not be aware of the individualisation of risk. Family physicians should be aware of these optimistic expectations, because these can influence the doctor–patient relationship when discussing these interventions and incorporating personalised risk.

The aim of the study was to investigate the meaning of narrated symptoms in connection to takotsubo syndrome.

Design, method, participants and setting

Qualitative study consisting of 25 interviews, 23 women and 2 men aged 39–84 and living in Region Västra Götaland, Sweden. The transcribed text was analysed with phenomenological hermeneutics.

Results

The interviewees reported a large number of symptoms before, during and after the acute onset of takotsubo syndrome, including pain, affected breathing, lassitude, malaise and nausea. Several of these have not been reported previously. Symptoms before the acute onset were, even if they had been prominent, ignored by the interviewees for various reasons. During the acute phase, the symptoms could no longer be ignored and the interviewees sought healthcare. The remaining residual symptom after discharge from hospital caused a great deal of worry because the interviewees feared that they would be permanent and they felt they could not live this way. On the whole, becoming ill and having a large number of symptoms greatly impacted the lives of the interviewees and made them re-evaluate how they had been living. Furthermore, they reported feeling alone and lost regarding their symptom burden, especially in relation to their residual symptoms, which affected their health and ability to return to daily life.

Conclusions

Acute symptoms, and symptoms before and after the acute ones, are a major part of the illness experience for patients with takotsubo syndrome and affect their health and well-being. Assessment of symptoms should be an integrated part of care to promote health. One way of achieving this is through the patients’ own narratives of their experiences, which are an important component in person-centred care.

To conduct a rigorous feasibility study for a future definitive parallel-group randomised controlled trial (RCT) and economic evaluation of an enhanced rehabilitation package for hip fracture.

Setting

Recruitment from 3 acute hospitals in North Wales. Intervention delivery in the community.

Participants

Older adults (aged ≥65) who received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by clinical team) and received rehabilitation in the North Wales area.

Primary: Barthel Activities of Daily Living (BADL). Secondary measures included Nottingham Extended Activities of Daily Living scale (NEADL), EQ-5D, ICECAP capability, a suite of self-efficacy, psychosocial and service-use measures and costs. Outcome measures were assessed at baseline and 3-month follow-up by blinded researchers.

Results

62 participants were recruited, 61 randomised (control 32; intervention 29) and 49 (79%) completed 3-month follow-up. Minimal differences occurred between the 2 groups for most outcomes, including BADL (adjusted mean difference 0.5). The intervention group showed a medium-sized improvement in the NEADL relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d 0.63), and a trend for greater improvement in self-efficacy and mental health, but with small effect sizes. The mean cost of delivering the intervention was £231 per patient. There was a small relative improvement in quality-adjusted life year in the intervention group. No serious adverse events relating to the intervention were reported.

Conclusions

The trial methods were feasible in terms of eligibility, recruitment and retention. The effectiveness and cost-effectiveness of the rehabilitation package should be tested in a phase III RCT.

To assess trends in prescribing practices of antidiabetic agents and glycaemic control in patients with type 2 diabetes mellitus (T2DM).

Design

Cross-sectional analysis using yearly clinical data and antidiabetic treatments prescribed obtained from an electronic population database.

Setting

Primary healthcare centres, including the entire population attended by the Institut Català de la Salut in Catalonia, Spain, from 2007 to 2013.

Participants

Patients aged 31–90 years with a diagnosis of T2DM.

Results

The number of registered patients with T2DM in the database was 257 072 in 2007, increasing up to 343 969 in 2013. The proportion of patients not pharmacologically treated decreased by 9.7% (95% CI –9.48% to –9.92%), while there was an increase in the percentage of patients on monotherapy (4.4% increase; 95% CI 4.16% to 4.64%), combination therapy (2.8% increase; 95% CI 2.58% to 3.02%), and insulin alone or in combination (increasing 2.5%; 95% CI 2.2% to 2.8%). The use of metformin and dipeptidyl peptidase-IV inhibitors increased gradually, while sulfonylureas, glitazones and α-glucosidase inhibitors decreased. The use of glinides remained stable, and the use of glucagon-like peptide-1 receptor agonists was still marginal. Regarding glycaemic control, there were no relevant differences across years: mean glycated haemoglobin (HbA1c) value was around 7.2%; the percentage of patients reaching an HbA1c≤7% target ranged between 52.2% and 55.6%; and those attaining their individualised target from 72.8% to 75.7%.

Conclusions

Although the proportion of patients under pharmacological treatment increased substantially over time and there was an increase in the use of combination therapies, there have not been relevant changes in glycaemic control during the 2007–2013 period in Catalonia.

This study aimed to compare classification of pressure ulcers from administrative data with a gold standard assessment, specifically; pressure ulcers confirmed by an independent physical assessment performed by trained nurse surveyors.

Setting

A retrospective analysis of pooled cross-sectional samples of inpatients assessed across 3 consecutive prevalence surveys in a large academic health sciences centre between 2012 and 2013.

Participants

There were 2001 patients for whom physical and chart assessments were completed, and for whom a discharge abstract was also available at the time of analysis. The cohort's mean age was 65 years and 55% were women.

Results

Based on the physical assessment findings, 14.6% of patients (n=292) had at least 1 pressure ulcer, with a total of 345 pressure ulcers documented among these patients: (stage I=162; stage II=120; stage III=22; stage IV=22 and unstageable=19). Based on coded information, 78 (3.9%) of patients had a pressure ulcer. Of patients with a pressure ulcer determined by the physical assessment, only 21% also had a pressure ulcer captured in the administrative data. Furthermore, only 6% of the patients with a hospital-acquired pressure ulcer, stage II or greater determined by the physical assessment were coded in the Discharge Abstract Database (DAD).

Conclusions

The results of this study demonstrate that coding in the DAD may under-report and fail to accurately reflect the true burden of pressure ulcers in hospitalised patients. This may occur because the presence of pressure ulcers is currently documented in the health record by nurses and not by physicians, yet the administrative data recorded in the DAD only includes physician documented pressure ulcers. We recommend enhancements to the coding methods to monitor and report on pressure ulcers.

To determine whether postoperative delirium predicts first-time readmissions and mortality in octogenarian patients within 180 days after aortic valve therapy with surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI), and to determine the most common diagnoses at readmission.

Tertiary university hospital that performs all SAVRs and TAVIs in Western Norway.

Participants

Patients 80+ years scheduled for SAVR or TAVI and willing to participate in the study were eligible. Those unable to speak Norwegian were excluded. Overall, 143 patients were included, and data from 136 are presented.

Primary and secondary outcome measures

The primary outcome was a composite variable of time from discharge to first all-cause readmission or death. Secondary outcomes were all-cause first readmission alone and mortality within 180 days after discharge, and the primary diagnosis at discharge from first-time readmission. Delirium was assessed with the confusion assessment method. First-time readmissions, diagnoses and mortality were identified in hospital information registries.

Results

Delirium was identified in 56% of patients. The effect of delirium on readmissions and mortality was greatest during the first 2 months after discharge (adjusted HR 2.9 (95% CI 1.5 to 5.7)). Of 30 first-time readmissions occurring within 30 days, 24 (80%) were patients who experienced delirium. 1 patient (non-delirium group) died within 30 days after therapy. Delirious patients comprised 35 (64%) of 55 first-time readmissions occurring within 180 days. Circulatory system diseases and injuries were common causes of first-time readmissions within 180 days in delirious patients. 8 patients died 180 days after the procedure; 6 (75%) of them experienced delirium.

Conclusions

Delirium in octogenarians after aortic valve therapy might be a serious risk factor for postoperative morbidity and mortality. Cardiovascular disorders and injuries were associated with first-time readmissions in these patients.

We sought whether simple clinical markers could be used in a questionnaire for recognition of inappropriate (or rarely appropriate, RA) tests at point-of-service. Most applications of appropriateness criteria (AC) for transthoracic echocardiogram (TTE) have been at the point of order, but a simple means of identifying RA tests in an audit process would be of value.

Design, setting and participants

The study was performed in 2 major hospitals in Tasmania. 2 reviewers created a questionnaire based on 4 questions most commonly associated with RA (suspected endocarditis with no positive blood cultures or new murmur, lack of cardiovascular symptoms or no change in clinical status or cardiac examination, routine surveillance and previous TTE within a year) in a derivation cohort of 814 patients. This was prospectively applied to 499 TTEs to calculate sensitivity and specificity for prediction of RA, and validated in the external group (n=880).

Results

Of 499 prospective TTEs, the questionnaire selected 18% requests as being potentially RA. As 7.4% were actually RA ( 89%), the sensitivity and specificity of the questionnaire were 84% and 87%, respectively. In the external validation cohort, the model found 11% requests needed to be screened for appropriateness with a sensitivity and specificity of 80% and 95%.

Conclusions

A questionnaire based on 4 questions detects a high proportion of RA TTE, and could be used for audit.

Main study aim was as follows: (1) to explore the usefulness of the theory of planned behaviour (TPB) model in predicting Chinese hospital pharmacists' intention to provide clinical pharmacy services (CPSs), including auxiliary CPSs and core CPSs; (2) to identify the main factors affecting the Chinese hospital pharmacists' intention to provide core CPSs based on TPB quantitatively.

Design

Cross-sectional questionnaire study.

Setting

The study was conducted in 22 general hospitals in seven cities located in the eastern and western part of China.

The TPB with the addition of PB is a useful framework for predicting pharmacists' intention to provide CPSs in Chinese hospital care context. Strategies to improve hospital pharmacists' intention to provide CPSs should focus on helping the individuals related medical care see the value of CPSs, altering their perception of social pressure towards core CPSs and the removal of obstacles that impede the translation of intentions into behaviour.

Smartphone games that aim to alter health behaviours are common, but there is uncertainty about how to achieve this. We systematically reviewed health apps containing gaming elements analysing their embedded behaviour change techniques.

Methods

Two trained researchers independently coded apps for behaviour change techniques using a standard taxonomy. We explored associations with user ratings and price.

Data sources

We screened the National Health Service (NHS) Health Apps Library and all top-rated medical, health and wellness and health and fitness apps (defined by Apple and Google Play stores based on revenue and downloads). We included free and paid English language apps using ‘gamification’ (rewards, prizes, avatars, badges, leaderboards, competitions, levelling-up or health-related challenges). We excluded apps targeting health professionals.

Few health apps currently employ gamification and there is a wide variation in the use of behaviour change techniques, which may limit potential to improve health outcomes. We found no correlation between user rating (a possible proxy for health benefits) and game content or price. Further research is required to evaluate effective behaviour change techniques and to assess clinical outcomes.

To determine the likely enrolment rate of eligible participants into a randomised controlled trial (RCT) in which a within-cast intermittent pneumatic compression device using Jet Impulse Technology (IPC/JIT) is 1 of 3 possible interventions in a RCT for the prevention of venous thromboembolism (VTE) in the clinical setting of isolated lower limb cast immobilisation.

Design

A prospective, open-label feasibility study of the IPC/JIT device placed within a lower limb cast.

The main outcome measure was the proportion of eligible participants who participated in the feasibility study. Secondary outcome measures included adherence to device usage throughout the study, ease of application of the device and adverse events potentially associated with its use.

Results

The proportion of potentially eligible participants for the IPC/JIT device was only 7/142 (5%), 95% CI 2 to 9.9. Devices were used for a mean (range) of 4.1 (1.9 to 10.2) hours per day and none of 7 participants had adequate adherence to the device. 3 of the 7 participants suffered an adverse event, including 1 deep vein thrombosis, 2 dorsal foot ulcer and 1 skin maceration.

Conclusions

A within-cast IPC/JIT device is unlikely to be a feasible randomisation arm for a RCT assessing possible interventions for the reduction of VTE risk in the clinical setting of lower limb injury requiring below knee cast immobilisation for a minimum of 4 weeks.

A high prevalence of PDN was found in rural community residents with type 2 diabetes and the healthcare workers provided little attention to, or treatment of, discomfort. It is important to identify high-risk groups with PDN early in order to prevent foot ulceration and reduce the incidence of amputation of the extremities. It is also urgent to develop appropriate treatment and self-relief behaviours to halt or reverse the progression of PDN for this population living in rural areas.

Better knowledge about tuberculosis (TB) and latent TB infection (LTBI) epidemiology is a crucial step for the development of effective strategies towards the control and elimination of this deadliest and persistent health threat. No study has investigated LTBI epidemiology in policemen who act as an interface with cross-border migrants.

Methods

A survey to measure the LTBI prevalence and assess the demographic, professional and clinical features potentially associated with tuberculin skin test (TST) positivity was performed in Italian State Police (ISP) employees engaged, even occasionally, in relief activities, hospitality, photographical identification, escorting and accompanying of migrants, regardless of contact with active TB cases. Variables potentially associated with TST positivity were evaluated with univariate and multivariate analysis.

Results

From September to December 2014, 4225 ISP workers underwent TST screening and completed the questionnaire for data collection, according to study procedures. The TST was positive in 9.9% of individuals: no active TB cases were registered among the entire study population. Age, previous BCG vaccination and work category resulted independently associated with TST positivity.

Conclusions

This is the first study providing updated data about LTBI epidemiology among ISP employees engaged in assistance to migrants and furnish preliminary evidence of possible associations between TST positivity and different conditions that need to be deeply investigated with prospective studies.

To identify typologies of experiences and coping strategies of men with rheumatoid arthritis (RA).

Design

Q-methodology (a qualitative and quantitative approach to grouping people according to their subjective opinion). Men with RA sorted 64 statements relating to their experience of living with RA according to level of agreement across a normal distribution grid. Data were examined using Q-factor analysis.

Setting

Rheumatology outpatient departments in the UK.

Participants

30 of 65 invited men with RA participated in this study (46%).

Results

All participants ranked highly the need to be well informed about their medication and the importance of keeping a positive attitude. 2 factors describing the experiences and coping strategies of male patients living with RA were identified: factor A: ‘acknowledge, accept and adapt’ (n=14) take a proactive approach to managing the impact of RA and find different ways of doing things; while factor B: ‘trying to match up to a macho ideal’ (n=8) are determined to continue with their pre-RA lives, and therefore push themselves to carry on even if this causes them pain. They are frustrated and angry due to the impact of RA but they internalise this rather than directing it at others.

Conclusions

While some men adapt to their RA by renegotiating their masculine identity, others struggle to relinquish their traditional masculine roles. Further research is needed to identify whether the finding that there are 2 distinct groups of men with RA can be generalised, and if so whether the differences can be explained by clinical, social or psychological factors, which may inform different therapeutic approaches.

Evidence of a ‘first night effect’ has been documented for polysomnography. The possibility of this has not been previously assessed in wrist actigraphy, yet may have important implications for the study design of future sleep research. We sought to examine potential evidence of a ‘first night effect’ for wrist actigraphy in adolescents across weekdays and weekend nights for multiple sleep outcomes.

Adolescents (aged 11–13 years at baseline) were recruited to the study and were requested to wear a wrist actigraph for 7 consecutive days/nights at baseline and then annually for 2 years during the second term of the academic year.

Primary outcome measures

We compared multiple sleep outcomes (total sleep time, wake after sleep onset, sleep efficiency, sleep onset latency, number of awakenings, length of awakenings, sleep onset time) when the device was worn on a weekday and weekend and compared these to other nights to identify possible evidence of a ‘first night effect’ for wrist actigraphy.

Results

No significant differences were found between any sleep outcomes when the first night of wrist actigraphy was on a weekday compared with other weekdays. When the first night was measured on a weekend (Friday), average total sleep time was significantly greater (486±5 min) compared with the second night (Saturday; 469±6 min), p=0.01.

Conclusions

We found no evidence to support a ‘first night effect’ for wrist actigraphy in our adolescent sample. The first night of actigraphy data should not be disregarded in future studies that deploy this technique to measure sleep over prolonged time periods.

Patient-reported outcome measures (PROMs) collected in clinical trials should be administered in a standardised way across sites and routinely screened for avoidable missing data in order to maximise data quality/minimise risk of bias. Recent qualitative findings, however, have raised concerns about the consistency of PROM administration in UK trials. The purpose of this study was to determine the generalisability of these findings across the wider community of trial personnel.

Design

Online cross-sectional survey.

Setting

Participants were recruited from 55 UK Clinical Research Collaboration Registered Clinical Trials Units and 19 Comprehensive Local Research Networks.

We undertook descriptive analyses of the quantitative data and directed thematic analysis of free-text comments. Factors associated with the management of missing PRO data were explored using logistic regression.

Results

Survey data from 767 respondents supported the generalisability of qualitative study findings, suggesting inconsistencies in PROM administration with regard to: the level of assistance given to trial participants; the timing of PROM completion in relation to the clinical consultation; and the management of missing data. Having ≥10 years experience in a research role was significantly associated with the appropriate management of missing PROM data (OR 2.26 (95% CI 1.06 to 4.82), p=0.035). There was a consensus that more PROM guidance was needed in future trials and agreement between professional groups about the necessary components.

Conclusions

There are inconsistencies in the way PROMs are administered by trial staff. Such inconsistencies may reduce the quality of data and have the potential to introduce bias. There is a need for improved guidance in future trials that support trial personnel in conducting optimal PROM data collection to inform patient care.

Recommendations regarding physical activity typically include both leisure time and occupational physical activity. However, the results from previous studies on occupational physical activity and the association with myocardial infarction have been inconsistent. The aim of this study was to investigate if occupational physical activity is associated with the risk of myocardial infarction.

Design

Prospective cohort study.

Participants

Data from the Swedish Work, Lipids and Fibrinogen (WOLF) study was used, comprising 9961 employees (6849 men, 3112 women, mean age 42.7 years) having no history of myocardial infarction. The participants were categorised into 3 groups according to their level of occupational physical activity.

Outcome

Data regarding incident myocardial infarction were obtained from the Swedish National Patient Register and the Cause of Death Register. Cox proportional hazard regression was used for estimation of HRs for different levels of occupational physical activity in relation to the risk of myocardial infarction.

Results

During a mean follow-up of 13.1 years, 249 cases of incident myocardial infarction were identified. In analyses adjusted for age, sex and socioeconomic status, participants standing and walking more than 50% of their working day had an HR of 1.13 (95% CI 0.83 to 1.54), compared with participants seated more than 50% of their working day. The corresponding HR for participants whose work included lifting or carrying was 0.86 (95% CI 0.59 to 1.24). Further adjustment did not alter the results. Stratified analyses resulted in a significantly decreased risk for young people whose work included lifting or carrying, HR 0.37 (95% CI 0.17 to 0.84), compared with younger persons who sat most of their working day.

Conclusions

No significant association between occupational physical activity and the risk of myocardial infarction was observed in the total group of employees in this study. Based on the results from this study, occupational physical activity in general does not seem to be enough for reducing the risk of myocardial infarction.

The prevalence of hyperuricemia and gout has increased in recent decades. The role of dietary fructose in the development of these conditions remains unclear.

Objective

To conduct a systematic review and meta-analysis of prospective cohort studies investigating the association fructose consumption with incident gout and hyperuricemia.

Design

MEDLINE, EMBASE and the Cochrane Library were searched (through September 2015). We included prospective cohort studies that assessed fructose consumption and incident gout or hyperuricemia. 2 independent reviewers extracted relevant data and assessed study quality using the Newcastle-Ottawa Scale. We pooled natural-log transformed risk ratios (RRs) using the generic inverse variance method. Interstudy heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic). The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

2 studies involving 125 299 participants and 1533 cases of incident gout assessed the association between fructose consumption and incident gout over an average of 17 years of follow-up. No eligible studies assessed incident hyperuricemia as an outcome. Fructose consumption was associated with an increase in the risk of gout (RR=1.62, 95% CI 1.28 to 2.03, p<0.0001) with no evidence of interstudy heterogeneity (I2=0%, p=0.33) when comparing the highest (>11.8% to >11.9% total energy) and lowest (<6.9% to <7.5% total energy) quantiles of consumption.

Limitations

Despite a dose–response gradient, the overall quality of evidence as assessed by GRADE was low, due to indirectness. There were only two prospective cohort studies involving predominantly white health professionals that assessed incident gout, and none assessed hyperuricemia.

Conclusions

Fructose consumption was associated with an increased risk of developing gout in predominantly white health professionals. More prospective studies are necessary to understand better the role of fructose and its food sources in the development of gout and hyperuricemia.

This study outlines the development of a patient-reported outcome measure (PROM), an instrument to obtain self-reported health status for neuromyeltis optica (NMO), a disabling neurological condition.

Design

Development was conducted in accordance with international guidance for PROMs including systematic review of existing literature, item generation guided by qualitative interviews, health-related quality of life conceptual framework and clinical expert panel and cognitive interviews with NMO patients.

Setting

Participants were identified through a national NMO clinic in a tertiary NHS neurosciences service.

Participants endorsed the draft instrument as reflecting their experience of the condition and as being easy to understand. Rating and ranking of item relevance and importance reduced the draft instrument from 106 to 48 items. Participant feedback on overlapping items eliminated a further 2 items and resulted in a preliminary instrument of 46 items. As a direct result of participant feedback ordering of the 10 domains was revised, a 4 option Likert scale was employed and a 4-week recall period for impact of symptoms was selected.

Conclusions

A 46-item instrument developed in accordance with international PROM development guidelines through literature review, developed by subject matter experts and refined through pretesting examining content validity provides a preliminary measure for assessing patient-report of health status in NMO. Further evaluation is proposed including sensitivity to clinical change, and international contributions to evaluating the measure are encouraged.

From the late 1980s ‘Back-to-Sleep’ (BTS) campaigns were run in most developed countries to increase awareness of the supine position's protective effect against sleep-related infant deaths. Once the media awareness-raising action associated with these campaigns ended, healthcare professionals' role became crucial. The goal of this paper is to determine if healthcare professionals' knowledge and parent advice consistent with evidence-based infant sleep recommendations have changed over the past 20 years.

Setting

All studies investigating healthcare professionals' knowledge and/or advice to parents were included in a systematic review. The search was performed in PubMed and in MEDLINE, and 21 studies were identified.

Results

The correctness of healthcare professionals' knowledge and parent advice about the supine sleeping position increased over the past 20 years. However, the percentage of those aware that parents should avoid putting their babies to sleep in a prone position is decreasing over time: from about 97% in the 1990s to about 90% at the end of the 2000s.

Conclusions

The effectiveness of the BTS campaigns in publicising the benefits of the supine position is confirmed by this paper. More and more healthcare professionals know that it is the best position to reduce the risk of sleep-related deaths and they recommend it exclusively. However, the decrease in the knowledge about non-prone positions suggests that the campaigns may not have focused enough on the dangers of the prone position.

Second victims are healthcare workers who experience emotional distress following patient adverse events. Studies indicate the need to develop organisational support programmes for these workers. The RISE (Resilience In Stressful Events) programme was developed at the Johns Hopkins Hospital to provide this support.

Objective

To describe the development of RISE and evaluate its initial feasibility and subsequent implementation. Programme phases included (1) developing the RISE programme, (2) recruiting and training peer responders, (3) pilot launch in the Department of Paediatrics and (4) hospital-wide implementation.

Methods

Mixed-methods study, including frequency counts of encounters, staff surveys and evaluations by RISE peer responders. Descriptive statistics were used to summarise demographic characteristics and proportions of responses to categorical, Likert and ordinal scales. Qualitative analysis and coding were used to analyse open-ended responses from questionnaires and focus groups.

Results

A baseline staff survey found that most staff had experienced an unanticipated adverse event, and most would prefer peer support. A total of 119 calls, involving ~500 individuals, were received in the first 52 months. The majority of calls were from nurses, and very few were related to medical errors (4%). Peer responders reported that the encounters were successful in 88% of cases and 83.3% reported meeting the caller's needs. Low awareness of the programme was a barrier to hospital-wide expansion. However, over the 4 years, the rate of calls increased from ~1–4 calls per month. The programme evolved to accommodate requests for group support.

Conclusions

Hospital staff identified the need for a multidisciplinary peer support programme for second victims. Peer responders reported success in responding to calls, the majority of which were for adverse events rather than for medical errors. The low initial volume of calls emphasises the importance of promoting awareness of the value of emotional support and the availability of the programme.

This study aimed to evaluate the association of neck circumference (NC) with obesity to determine the sex-specific and age-specific optimal cut-off points of this measure in association with obesity in a national sample of the Iranian paediatric population.

Methods

This survey on weight disorders was conducted among a national sample of Iranian children and adolescents, aged 6–18 years. Using the area under the curve (AUC) of the receiver operator characteristic curves, we evaluated the association of NC with general and abdominal obesity.

Results

This national survey was conducted among 23 043 school students (50.8% boys) with a mean age (SD) of 12.55 (3.31) years. A significant association was documented between NC and other anthropometric measures in both sexes and in the whole population. In all age groups and genders, NC performed relatively well in classifying participants to overweight (AUC: 0.67 to 0.75, p<0.001), general obesity (AUC: 0.81 to 0.85, p<0.001) and abdominal obesity (AUC: 0.73 to 0.78, p<0.001).

Conclusions

NC can be considered as a simple time-saving clinical tool for obesity detection in large population-based studies in children and adolescents. It is significantly correlated with indices of adiposity and can reliably identify children with general and abdominal obesity in the Iranian paediatric population.

To capture the clinical patterns, timing of key milestones and survival of patients presenting with amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) within Australia.

Methods

Data were prospectively collected and were timed to normal clinical assessments. An initial registration clinical report form (CRF) and subsequent ongoing assessment CRFs were submitted with a completion CRF at the time of death.

Design

Prospective observational cohort study.

Participants

1834 patients with a diagnosis of ALS/MND were registered and followed in ALS/MND clinics between 2005 and 2015.

Results

5 major clinical phenotypes were determined and included ALS bulbar onset, ALS cervical onset and ALS lumbar onset, flail arm and leg and primary lateral sclerosis (PLS). Of the 1834 registered patients, 1677 (90%) could be allocated a clinical phenotype. ALS bulbar onset had a significantly lower length of survival when compared with all other clinical phenotypes (p<0.004). There were delays in the median time to diagnosis of up to 12 months for the ALS phenotypes, 18 months for the flail limb phenotypes and 19 months for PLS. Riluzole treatment was started in 78–85% of cases. The median delays in initiating riluzole therapy, from symptom onset, varied from 10 to 12 months in the ALS phenotypes and 15–18 months in the flail limb phenotypes. Percutaneous endoscopic gastrostomy was implemented in 8–36% of ALS phenotypes and 2–9% of the flail phenotypes. Non-invasive ventilation was started in 16–22% of ALS phenotypes and 21–29% of flail phenotypes.

Conclusions

The establishment of a cohort registry for ALS/MND is able to determine clinical phenotypes, survival and monitor time to key milestones in disease progression. It is intended to expand the cohort to a more population-based registry using opt-out methodology and facilitate data linkage to other national registries.

To investigate the effects of vitreomacular adhesion (VMA), vitreomacular separation (VMS) and absence of vitreous gel due to vitrectomy on macular thickness measured in the spectral domain optical coherence tomographic (SD-OCT) images.

Design

A longitudinal, retrospective, observational study.

Setting

Secondary multicentre study.

Participants

218 eyes of 218 healthy patients and 119 vitrectomised eyes of 119 patients were studied. The healthy individuals were classified into a VMA group (54 eyes) and a VMS group (164 eyes), while the vitrectomised patients were classified into an internal limiting membrane (ILM)-on group (26 eyes) and an ILM-off group (93 eyes). In all participants, 2 Cirrus HD-OCT recordings were made with an average interval of 36 months (range 24–60 months).

Primary and secondary outcome measures

The primary outcome measure was the rate of change in macular thickness in the central sector. The secondary outcomes were the rates of change in macular thickness in the inner 4 sectors.

Results

The annual rate of change in the macular thickness of the central sector was 0.76±1.8 µm/year in the VMA group, –0.58±2.3 µm/year in the VMS group, –1.57±1.9 µm/year in the ILM-on group and –0.86±3.1 µm/year in the ILM-off group. There was a significant difference between the rate of the central sector thickness change in the VMA and VMS groups (p=0.0001). The presence of VMA was a significant factor associated with an increase in the central sector thickness (p=0.0055). When the healthy and ILM-on groups were compared, the rate of decrease in the central sector thickness was faster in the ILM-on group (p=0.0043). Multiple regression analyses showed that not peeling the ILM during the vitrectomy was a significant factor associated with a decrease in the central sector thickness (p=0.044).

Conclusions

The presence of a VMA and a vitreous gel may help restrain the macular thickness reduction.

Increasingly, English local authorities have encouraged the implementation of an intervention called ‘Reducing the Strength’ (RtS) whereby off-licences voluntarily stop selling inexpensive ‘super-strength’ (≥6.5% alcohol by volume (ABV)) beers and ciders. We conceptualised RtS as an event within a complex system in order to identify pathways by which the intervention may lead to intended and unintended consequences.

Design

A qualitative study including a focus group and semistructured interviews.

Setting

An inner-London local authority characterised by a high degree of residential mobility, high levels of social inequality and a large homeless population. Intervention piloted in three areas known for street drinking with a high alcohol outlet density.

Participants describe a range of potential substitution behaviours to circumvent alcohol availability restrictions including consuming different drinks, finding alternative shops, using drugs or committing crimes to purchase more expensive drinks. Service providers suggested the intervention delivered in this local authority missed opportunities to encourage engagement between the council, alcohol services, homeless hostels and off-licence stores. Some participants believed small-scale interventions such as RtS may facilitate new forms of engagement between public and private sector interests and contribute to long-term cultural changes around drinking, although they may also entrench the view that ‘problem drinking’ only occurs in certain population groups.

Conclusions

RtS may have limited individual-level health impacts if the target populations remain willing and able to consume alternative means of intoxication as a substitute for super-strength products. However, RtS may also lead to wider system changes not directly related to the consumption of super-strengths and their assumed harms.

Delayed discharges are a significant problem for the National Health Service. The objectives of this study were to determine the prevalence and impact of delayed discharge at a single specialist vascular surgery ward.

Design

A cross-sectional observational study.

Setting

A single specialist vascular unit in the UK during a 4-month study period (01/09/2014–31/12/2014).

Participants

All patients admitted to the ward during the study period were included. Patients spending ≥1 night on the ward once declared medically fit for discharge (MFFD) were prospectively identified and data prospectively collected. All other patients were identified retrospectively with data collected retrospectively from electronic records.

Outcome measures

Primary outcome was number of patients experiencing delayed discharge. Secondary outcome measures were length of stay, length of delay and cost of delay.

Results

There were 268 admissions with a total length of stay (LoS) of 2776 days. 57 admissions (21.3%) experienced delayed discharges with a total 535 excess bed days (19.3% total LoS) once MFFD. Unplanned admission (relative risk 7.3 (95% CI 2.7 to 20.0; p<0.001)) and index amputation (relative risk 9.2 (95% CI 3.8 to 22.0; p<0.001)) were associated with increased risk of delayed discharge. There were significant differences in the length of delay by the reason for the delay (p=0.01). Delay due to the provision of social services and inpatient rehabilitation were associated with longer length of delay (post hoc analysis). Age was not independently associated with either increased risk of delayed discharge or length of delay.

The total estimated cost of delayed discharges during the study period was £146 055.

Conclusions

A significant number of vascular patients experience delayed discharge. MFFD vascular patients occupy a high proportion of vascular beds at considerable financial cost. Unplanned admissions, amputees and those delayed due to social services contributed most to delays. Closer integration with community health and social care providers may reduce delays.

Screening for prostate cancer remains controversial. General practitioners (GPs) play an important role in assisting men to make an informed decision on prostate cancer screening. The aim of this study was to determine the knowledge and practice of prostate cancer screening among private GPs in Malaysia.

Design

A cross-sectional study.

Setting

Private general practices in Selangor, Malaysia.

Participants

311 randomly selected full-time private GPs were recruited between September 2013 and January 2014.

Outcome measures

Questionnaires were distributed to the GPs via postal mail and clinic visits. The main outcomes were: knowledge of prostate cancer risk factors and screening tests; GPs' prostate cancer screening practices; and factors influencing GPs' decision to screen for prostate cancer. Associations between covariates and propensity to screen for prostate cancer were determined using logistic regression.

Results

The response rate was 65%. The proportion of GPs who overestimated the positive predictive values of prostrate-specific antigen (PSA), digital rectal examination (DRE) and a combination of PSA and DRE was 63%, 57% and 64%, respectively. About 49.5% of the respondents would routinely screen asymptomatic men for prostate cancer; of them, 94.9% would use PSA to screen. Male GPs who would consider having a PSA test performed on themselves were six times more likely to screen asymptomatic men than GPs who would not have the test (OR=6.88, 95% CI 1.40 to 33.73), after adjusting for age and duration of practice.

Conclusions

GPs overestimated the accuracy of PSA in prostate cancer screening. Their intention to screen for prostate cancer themselves predicted their propensity to screen their patients for prostate cancer. This finding highlights the potential of using a new approach to change GPs' screening practices via addressing GPs' own screening behaviour.

This research studies the impact of influenza epidemic in the slum and non-slum areas of Delhi, the National Capital Territory of India, by taking proper account of slum demographics and residents’ activities, using a highly resolved social contact network of the 13.8 million residents of Delhi.

Methods

An SEIR model is used to simulate the spread of influenza on two different synthetic social contact networks of Delhi, one where slums and non-slums are treated the same in terms of their demographics and daily sets of activities and the other, where slum and non-slum regions have different attributes.

Results

Differences between the epidemic outcomes on the two networks are large. Time-to-peak infection is overestimated by several weeks, and the cumulative infection rate and peak infection rate are underestimated by 10–50%, when slum attributes are ignored.

Conclusions

Slum populations have a significant effect on influenza transmission in urban areas. Improper specification of slums in large urban regions results in underestimation of infections in the entire population and hence will lead to misguided interventions by policy planners.

Frequent users of healthcare services are a vulnerable population, often socioeconomically disadvantaged, who can present multiple chronic conditions as well as mental health problems. Case management (CM) is the most frequently performed intervention to reduce healthcare use and cost. This study aimed to examine the evidence of the effectiveness of CM interventions for frequent users of healthcare services.

Design

Scoping review.

Data sources

An electronic literature search was conducted using the MEDLINE, Scopus and CINAHL databases covering January 2004 to December 2015. A specific search strategy was developed for each database using keywords ‘case management’ and ‘frequent use’.

Eligibility criteria for selecting studies

To be included in the review, studies had to report effects of a CM intervention on healthcare use and cost or patient outcomes. Eligible designs included randomised and non-randomised controlled trials and controlled and non-controlled before–after studies. Studies limited to specific groups of patients or targeting a single disease were excluded. Three reviewers screened abstracts, screened each full-text article and extracted data, and discrepancies were resolved by consensus.

Results

The final review included 11 articles evaluating the effectiveness of CM interventions among frequent users of healthcare services. Two non-randomised controlled studies and 4 before–after studies reported positives outcomes on healthcare use or cost. Two randomised controlled trials, 2 before–after studies and 1 non-randomised controlled study presented mitigated results. Patient outcomes such as drug and alcohol use, health locus of control, patient satisfaction and psychological functioning were evaluated in 3 studies, but no change was reported.

Conclusions

Many studies suggest that CM could reduce emergency department visits and hospitalisations as well as cost. However, pragmatic randomised controlled trials of adequate power that recruit the most frequent users of healthcare services are still needed to clearly confirm its effectiveness.

The evidence for patient-safety interventions implemented in hospitals worldwide is weak. The findings address the need to invest in high-quality research standards in order to identify interventions that have a real impact on patient safety. Interventions to prevent delirium, cardiopulmonary arrest and mortality, adverse drug events, infections and falls are most effective and should therefore be prioritised by clinicians.

In light of concerns for meeting the provision of healthcare services given the large numbers of ageing baby boomers, we compared the trajectories of primary care and specialist services use across the lifecourse of 5 birth cohorts and examined factors associated with birth cohort differences.

Although the overall pattern suggested less use of physician services by each successive recent cohort, this blinded differences in primary and specialist care use by cohort. Multilevel analyses comparing cohorts showed that Gen Xers and younger boomers, particularly those with multimorbidity, were less likely to use primary care than earlier cohorts. In contrast, specialist use was higher in recent cohorts, with Gen Xers having the highest specialist use. These increases were explained by the increasing levels of multimorbidity. Education, income, having a regular source of care, sedentary lifestyle and obesity were significantly associated with physician services use, but only partially contributed to cohort differences.

Conclusions

The findings suggest a shift from primary care to specialist care among recent cohorts, particularly for those with multimorbidity. This is of concern given policies to promote primary care services to prevent and manage chronic conditions. There is a need for policies to address important generational differences in healthcare preferences and the balance between primary and specialty care to ensure integration and coordination of healthcare delivery.

Studies published after transcatheter aortic valve insertion (TAVI) became available (2002).

Participants

Adults with aortic stenosis who are considering or have had valve replacement, either TAVI or via surgery (surgical aortic valve replacement, SAVR).

Outcome measures

We sought quantitative measurements, or qualitative descriptions, of values and preferences. When reported, we examined correlations between preferences and objective (eg, ejection fraction) or subjective (eg, health-related quality of life) measures of health.

Results

We reviewed 1348 unique citations, of which 2 studies proved eligible. One study of patients with severe aortic stenosis used a standard gamble study to ascertain that the median hypothetical mortality risk patients were willing to tolerate to achieve full health was 25% (IQR 25–50%). However, there was considerable variability; for mortality risk levels defined by current guidelines, 130 participants (30%) were willing to accept low-to-intermediate risk (≤8%), 224 (51%) high risk (>8–50%) and 85 (19%) a risk that guidelines would consider prohibitive (>50%). Study authors did not, however, assess participants' understanding of the exercise, resulting in a potential risk of bias. A second qualitative study of 15 patients identified the following factors that influence patients to undergo assessment for TAVI: symptom burden; expectations; information support; logistical barriers; facilitators; obligations and responsibilities. The study was limited by serious risk of bias due to authors' conflict of interest (5/9 authors industry-funded).

Conclusions

Current evidence on patient values and preferences of adults with aortic stenosis is very limited, and no studies have enrolled patients deciding between TAVI and SAVR. On the basis of the data available, there is evidence of variability in individual values and preferences, highlighting the importance of well-informed and shared decision-making with patients facing this decision.

To investigate the accuracy of the National Early Warning Score (NEWS) to predict mortality and adverse clinical outcomes for patients with community-acquired pneumonia (CAP) compared to standard risk scores such as the pneumonia severity index (PSI) and CURB-65.

Design

Secondary analysis of patients included in a previous randomised-controlled trial with a median follow-up of 6.1 years.

Settings

Patients with CAP included on admission to the emergency departments (ED) of 6 tertiary care hospitals in Switzerland.

Participants

A total of 925 patients with confirmed CAP were included. NEWS, PSI and CURB-65 scores were calculated on admission to the ED based on admission data.

Main outcome measure

Our primary outcome was all-cause mortality within 6 years of follow-up. Secondary outcomes were adverse clinical outcome defined as intensive care unit (ICU) admission, empyema and unplanned hospital readmission all occurring within 30 days after admission. We used regression models to study associations of baseline risk scores and outcomes with the area under the receiver operating curve (AUC) as a measure of discrimination.

Results

6-year overall mortality was 45.1% (n=417) with a stepwise increase with higher NEWS categories. For 30 day and 6-year mortality prediction, NEWS showed only low discrimination (AUC 0.65 and 0.60) inferior compared to PSI and CURB-65. For prediction of ICU admission, NEWS showed moderate discrimination (AUC 0.73) and improved the prognostic accuracy of a regression model, including PSI (AUC from 0.66 to 0.74, p=0.001) and CURB-65 (AUC from 0.64 to 0.73, p=0.015). NEWS was also superior to PSI and CURB-65 for prediction of empyema, but did not well predict rehospitalisation.

Conclusions

NEWS provides additional prognostic information with regard to risk of ICU admission and complications and thereby improves traditional clinical-risk scores in the management of patients with CAP in the ED setting.